IDENTIFYING INFORMATION (*required)

Agency:
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Agency Street Address, City, Zip:
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Agency Phone (with Area Code)
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Agency Fax (with Area Code)
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Contact Person First & Last Name:
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Email:
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Website:
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AGENCY INFORMATION

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:

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


Special requirements for interns considering this agency:

Field Instructor First & Last Name:
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Field Instructor Title:

Field Instructor Unit:

Field Instructor Degree:

Field Instructor 2nd Degree (if applicable):