Field Agency Application

IDENTIFYING INFORMATION (*required)

Agency:
*         

Agency Street Address, City, Zip:
 *

Agency Phone (with Area Code)
 *		 Agency Fax (with Area Code)
 *

Contact Person First & Last Name:
 * 

Email:
 *

Website:
 *


AGENCY INFORMATION

Check the practice area(s) which apply to your agency:

Mental Health Family Services Substance Abuse
Mental Retardation Services to the Aged Corrections
Medical/Health Community Organization Public Welfare
Children & Youth School Social Work  
 
Agency Hours:
 
If other hours or working arrangements are required (i.e., evenings, weekends), please specify:

Number of Intern Placements Available Per Semester:

Intern Placements Available (check all that apply): Fall     Spring

Briefly describe the purpose and function of this agency:

Briefly describe potential intern learning opportunities with individuals, families and small groups:

Briefly describe potential intern learning opportunities with organizations and community systems:

Please provide the following information about the clientele served by this agency:

Age Group of Clients  
% Infants (0-18 months) % Young Adults (18-25)
% Preschool Children % Adults
% Elementary School Children % Elderly (over 65)
% Adolescents  
   
Primary Intervention Unit  
% Individuals % Organizations
% Couples % Communities
% Families % Other
% Groups  
   
Client Race/Gender Client Income Status
% White Females % Low Income
% Females of Color % Urban Residents
% White Males % Rural Residents
% Males of Color  

What are the primary presenting problems of the clients the intern would serve?

Special requirements for interns considering this agency:

FIELD INSTRUCTOR INFORMATION

Field Instructor First & Last Name:
 *

Field Instructor Title:
 		Field Instructor Unit:

Field Instructor Degree:
 		Field Instructor 2nd Degree (if applicable):

Site Map | Directory | Questions?
©2006 Meredith College | 3800 Hillsborough Street, Raleigh, NC 27607-5298
Phone: (919)760-8348 | Fax: (919)760-8083