Professional Standing To the best of my knowledge I am in good standing with my Regulatory Body and/or Professional Association
Years of Clinical Counselling Experience * Do you have one full year of clinically-supervised experience in post degree? *YesNo
Other notable information
What supervisory role will you play in this practicum? *
Primary SupervisorCo-SupervisorOnsite SupervisorExternal Supervisor
If you are an external supervisor, please identify the person with whom you will have regular weekly or bi-weekly contact:
Will you be supervising more than one Yorkville University student concurrently *
YesNo
This section of the form corresponds to Ontario practitioners only. If you are not in Ontario, please proceed to the Supervisor Agreement section.
Which regulatory college are you a registrant of? College of Registered Psychotherapists of OntarioCollege of Nurses of OntarioCollege of Occupational Therapists of OntarioCollege of Physicians and Surgeons of OntarioCollege of Psychologists of OntarioOntario College of Social Workers & Social Service Workers Membership Type Ontario Clinical Requirements (Please refer to the College of Registered Psychotherapists of Ontario by clicking here.)I have checked the CRPO online registry and confirmed that I am cleared for independent practice. Please specify the number of years you have been practicing psychotherapy Have you completed 30 hours of directed learning in providing clinical supervision? YesNo If yes, please indicate your directed learning activities (select all that apply): Course WorkIndependent Study with Structured ReadingsIndividual / Peer / Group LearningSupervised Practice as a Clinical SupervisorOther Do you understand CRPO’s definitions of clinical supervision, clinical supervisor and the scope of practice of psychotherapy? YesNo
I acknowledge that I am not the Practicum Student's direct Employment Supervisor and/or current therapist (i.e., refraining from dual relationships as outlined in the Practicum Guide for Supervisors)*
I agree to uphold the requirements and procedures outlined in the Practicum Guide for Supervisors*
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:
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
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
I acknowledge that I have read the Site Affiliation Agreement and understand that I am legally binding the Practicum Site by submitting this form.*
