Professional Documents
Culture Documents
• Please complete this two (2) page form in order to begin the placement process for first year of field. This form will be
used to plan your field placement experience and will be sent to your field placement agency.
• Please note that there may be processing requirements for certain internships, such as: background checks, medical
screening, fingerprinting, etc. The student is responsible to pay for any costs associated with these requirements.
• IMPORTANT: Agencies are requiring background checks for employees and interns. If there is anything in your
background that you would like us to consider in placing you, please contact the Field Instruction office to discuss.
Name____________________________________________________ DOB_____________________________________
(Last) (First)
School E-Mail____________________________________________________________________
Are you enrolled in the Summer Block Program? (if yes, please indicate below in which program) Y_____ N_____
Are you an international student? Y_____ N_____ Do you speak a language other than English? Y_____ N_____
Special Factors:
Please list any factors/circumstances that should be taken into consideration when planning your field placement (e.g.) Geography,
time, physical condition, religious observance, family commitments, etc.:
Clinical Practice with Individuals and Families_____ Clinical Practice with Groups_____