WESTERN ILLINOIS UNIVERSITY | DEPARTMENT OF SOCIAL WORK
AGENCY PROFILE
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Date:__________________________
Agency:
Address:
City:
State:
Telephone:
Zip:
Fax:
Primary Field Instructor:
Secondary Contact Person:
Which semester(s) does the agency generally offer a practicum placement?
Fall
Spring
Summer
FIELD OF PRACTICE Check all that apply
PRACTICUM LEARNING OPPORTUNITIES
Stipend of $_________
Work Related Mileage $__________
Workshop/Conference Registration
Workshop/Conference Related Expenses
Lunches on Work Days
Agency Vehicle for Work Related Travel
Please note if the student’s involvement will be:
Direct (D): hands-on, either independently or in
conjunction with another worker; OR
Observation (O): view activity performed by others.
D O Advocacy
D O Budgeting
D O Care Planning
D O Case Management
D O Client Assessment
D O Client Counseling
D O Client Staffings
D O Community Relations
D O Community Planning
D O Counseling
D O Documentation
D O Evaluation or Research
D O Family Counseling
D O Fund Raising
D O Grant Writing
D O Group Work
D O Home Visits
D O In-Service Training
D O Inter-Agency Meetings
D O Intake
D O Interviewing
D O Program Development
D O Public Speaking
D O Referral
D O Staff Meetings
D O Teaching
D O Team Meetings/Projects
Other ____________________________________
D
Aging
Child Welfare
Crime/Delinquency
Developmental Disabilities
Domestic Violence
Education
Family Services
Financial Assistance
Health Care
Housing
Legal Services
Mental Health
Recreation
Rehabilitation
Substance Abuse
Sexual Abuse
POPULATIONS SERVED Check all that apply
Preschool Children
Elementary Aged Children
Adolescents
Young Adults
Middle Adults
Older Adults
PRACTICUM REQUIREMENTS Either regularly or
sometimes
Background Check
Use of Own Car
Professional Liability Insurance
Evening Hours
Weekend Hours
Home Visits
Physical Exam/Inoculations
Transporting Clients
Other ____________________________________
PRACTICUM SUPPORT Either regularly or sometimes
O
Other______________________________
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Agency Profile Update: 07/07