Site Contact Information

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).

If different from the person above, please list the Site Owner / Executive Director / etc below:

Site Details

Site Experience

This section refers to the experience that students will gain at the Practicum Site.

Applicable treatments * (Check as many as apply)Acceptance & Commitment Therapy (ACT)Adlerian Therapy (AT)Cognitive Behavioural Therapy (CBT)Dialectical Behavioural Therapy (DBT)Motivational Interviewing (MI)Narrative Therapy (NT)Person-Centred Therapy (Rogerian Therapy)Solution Focused Therapy (SFT)Gestalt Therapy (GT)Reality Therapy (RT)

Does the site require the practicum student to have any immunizations before starting practicum? *YesNo
Does the practicum site require the practicum student to have a mask fitting before starting practicum? *YesNo
Does the practicum site require the practicum student to have a criminal record check? *YesNo

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. *AgreeDisagree
Our mental health program / department was established prior to the Student's placement. *AgreeDisagree
Mental health will be the focus of the student's Practicum hours (not specialized treatment or advanced approaches to counselling). *AgreeDisagree
The student will not work with children under 10 years old or individuals without the cognitive ability to participate in talk therapy. *AgreeDisagree

Site Affiliation Agreement

I acknowledge that I have read the Site Affiliation Agreement and understand that I am legally binding the Practicum Site by submitting this form.*

YesNo