Supervisor Application

    Supervisor Contact Information


     

    Clinical Supervision Information


    What supervisory role will you play in this practicum? *

    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 *


     

    For Ontario Practitioners Only

    This section of the form corresponds to Ontario practitioners only. If you are not in Ontario, please proceed to the Supervisor Agreement section.



    (Please refer to the College of Registered Psychotherapists of Ontario by clicking here.)




     

    Supervisor Agreement

    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*



      Site Contact Information

      (Please insert legal name of Practicum Site)
      (if applicable, e.g: Alberta Health Services, Ministry of Child and Family Development, School Board or District, etc)
      (if applicable, this is your site’s link to Apply for Practicum)

      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

       

      (Check as many as apply)

       

      (Which areas will the student receive experience in)

       

      (Check as many as apply)

       


       

      Site Experience

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

      (Check as many as apply)

       



       


       

      Site Attestation

      As a Practicum Site, I attest to the following:




       


       

      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.*



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