Practicum Site Application

Practicum Sites must be on the Site Locator List in order to secure an approval for student placement. For a Practicum Site to be approved and placed on the Site Locator List, the Practicum Site must complete the following application form, which, if accepted, will form part of a legally binding agreement between the Practicum Site and Yorkville Education LP, together with the Practicum Affiliation Agreement.

Yorkville will indicate its acceptance of the application by approving the site. A physical mailed copy of the agreement will also be sent to the Authorized Person in the application form as the Official Site Contact. The person completing this form must be authorized to sign on behalf of the Practicum Site. Any questions or concerns can be submitted to [email protected]

Site Application

Authorized Person

Full name of authorized person filling out this form.
Title/position of authorized person filling out this form.

Site Contact Information

Please insert legal name of Practicum Site.
Please format number using dashes. Use an 'x' for extensions. E.g. 555-555-5555 x234
Do not use abbreviations. Please write out the province/state name in full.
If applicable, e.g. Alberta Health Services, Ministry of Child and Family Development, School Board or District, etc.
Please include the full URL. E.g. https://example.com

Official Site Contact

Please provide the name and contact information of the official contact person whom future students should contact regarding applying for a practicum at the agency. e.g. Executive Director, Field Placement Coordinator, etc.
Please format number using dashes. Use an 'x' for extensions. E.g. 555-555-5555 x234
If different from the person above, please list the Site Owner/Executive Director/etc. below:
Please format number using dashes. Use an 'x' for extensions. E.g. 555-555-5555 x234

Site Details

Check as many as apply. If inputting multiple items in the other field please separate each item with a comma.
Site Type
Service Provision Areas
Client Population Served

Site Experience

This section refers to the experience that students will gain at the Practicum Site.
Check as many as apply. If inputting multiple items in the other field please separate each item with a comma.
Applicable Treatments
Does the site require the practicum student to have any immunizations before starting practicum?
Does the practicum site require the practicum student to have a mask fitting before starting practicum?
Does the practicum site require the practicum student to have a criminal record check?

Site Attestation

As a Practicum Site, I attest to the following:
Our mental health program/department is established (prior to the Practicum start date) with policies and procedures.
Our mental health program / department was established prior to the Student's placement.
Mental health will be the focus of the student's Practicum hours (not specialized treatment or advanced approaches to counselling).
The student will not work with children under 10 years old or individuals without the cognitive ability to participate in talk therapy.

Site Affiliation Agreement

Acknowledgment

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