1
Supervision Contract/Agreement for
&
(Printed student name) (Semester / year)
MC Internship Supervision Agreement
This completed document denotes a supervisory agreement between the
specified graduate student in the Master of Counseling Program at Arizona State
University, and the agency & supervisor identified herein.
Student Name Date
Address
City
State ZIP
Preferred Phone
Alternate Phone
Email
Semester/Year
Hours per week
Internship Site Name
State ZIP
AZ License Number:
name and highest degree
Alternate Phone
Have you received training in Clinical Supervision? Y __ N__
Internship Start Date
Internship End Date
First Semester Internship Students: This agreement covers your entire (two semester) internship experience.
Use the academic calendar to locate the official end date of your second internship semester (date has been auto-
filled above). If you are unable to obtain all required hours by this date, you will submit an "Incomplete Letter of
Agreement" (form provided by CED684 instructor) containing a revised (estimated) end date. You will be released
from the revised agreement as soon as you have obtained 240 direct hours and 600 cumulative hours.
Address
City
Type of Agency
Site Supervisor:
Preferred Phone
Email
Revised 12/2020
(attach copy of license)
End date instructions:
Supervision Contract/Agreement for &
(Printed student name)
(Semester / year)
2
The internship experience is to provide the student with the opportunity to apply helping relationship skills
under qualified supervision in an applied organizational environment, while at the same time contributing to
the mission of the organization. As such, the student intern, site supervisor, and faculty/doctoral student
supervisor agree to all of the following:
THE STUDENT AGREES TO:
1. Adhere to the ACA code of ethics.
2.
Document a schedule with the site supervisor to work in the organization for a minimum of 300 hours
during each semester (2 semesters), normally twenty (20) hours per week, across the duration of
each 15-week semester. Interns must complete 120 hours of direct client contact and 180 hours of
indirect services such as case notes, supervision, evaluations, and services deemed necessary for
that site each semester.
3. Observe the working rules and professional standards of the organization under the supervision and to
provide a weekly log during every supervision accounting for time spent accruing direct and indirect hours
at the site.
4.
Observe the requirements of the internship course as outlined in the course syllabus.
5.
Provide site supervisor with a copy of the course syllabus during each semester of enrollment.
6.
Provide the MC Program Internship Instructor with a revised Site Agreement form should the site
supervisor information or weekly schedule change at any time.
THE SITE SUPERVISOR AGREES TO:
1.
Adhere to the code of ethics associated with the supervisors’ professional license.
2.
Provide the ASU Intern with a caseload to include a reasonable combination of individual and
group client hours. Specifically, the site agrees to provide a minimum of 8 direct client hours per week.
3.
Verify via signature/initials the student interns’ documentation of weekly hours via student provided
log.
4.
Be identified as the designated "Site Supervisor," and in this role, is identified as the person
responsible for providing direct supervision to the student for a minimum of one hour per week (All
supervisors of record must hold at least a Master’s degree and be licensed in the State of Arizona
in Counseling or a related field).
5.
Verify whether they have received training in clinical supervision (included in this agreement).
6.
In consultation with the supervised intern, document and provide supervisee with ongoing
feedback regarding their demonstrated knowledge, skill, and professional dispositions.
7.
Schedule periodic formal evaluative sessions throughout the supervisory relationship. Specifically, to
complete a
formal written evaluation of the student’s knowledge, skill and professional
dispositions
twice during each semester using the evaluation form provided by ASU’s Counseling Program and to
submit said evaluation with wet or verified electronic signature to both the student and the CED 684
Internship Instructor.
NOTE: Supervision of internship students includes program-appropriate
audio/video recordings and/or live supervision of students' interactions with clients.
8. Contact the CED684 Internship Instructor regarding any performance related concerns as soon as they
arise.
9. Keep a copy of this agreement.
THE FACULTY/DOCTORAL STUDENT SUPERVISORS AGREE TO:
1.
Adhere to the code of ethics associated with the supervisor’s professional license.
2.
Meet weekly for at least 1.5 hours for supervision, with a focus on promoting the development of
supervisee’s professional disposition, clinical competence and professional counselor identity via
written and/or verbal feedback
3.
Provide weekly group supervision during scheduled class time on campus
4.
Provide academic content for the supervisee’s Internship course as outlined in the course syllabus
5.
Consult with supervisee’s site supervisor at any time, and to document formative (midterm) and
summative (final) evaluations of the student’s professional dispositions, counseling performance and
ability to integrate and apply knowledge
6.
Consult with supervisee’s site supervisor as needed to determine final grade for the course.
Supervision Contract/Agreement for &
(Printed student name)
(Semester / year)
3
In accordance with ASU’s Master of Counseling Site Approval Policy, sites must be able to provide
the following activities/experiences to counseling interns: Individual, group, and family counseling, test
administration, case conceptualization, DSM-V diagnosis, treatment planning, access to diverse ethnic and
cultural groups, crisis counseling, and psychoeducational training (e.g., domestic violence, stress
management, anger management, relaxation training). Interns should be made aware of and document any
exceptions to these experiences. It is recommended that alternative experiences be discussed, agreed
upon and noted in this document.
The student’s weekly schedule at the internship site will be
as follows:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Notes:
The student’s responsibilities at the internship will be as follows:
Student Signature:
Site Supervisor Signature:
Internship Coordinator Signature:
Date:
Date:
Date:
The student and the supervisor jointly agree to work toward the following goals:
Backup Supervision Plan:
Provide the name and license number/type of a licensed individual who will
be on site and/or “on call” in the event of supervisor absence. Your supervisor will make arrangements
with this individual in advance of any planned or unexpected absence.
Telehealth/Remote Service
s Supervision Plan:
1) Describe the methods that you will use to contact your supervisor (include modality and specific
contact information):
2) Describe the specific types of circumstances that will require immediate consultation with your
supervisor while you are providing remote services to clients:
We jointly agree to the aforementioned stated terms and conditions of this applied experience:
