Masters of Counselling
Agency Agreement
PLEASE PRINT CLEARLY – OTHERWISE THE FORM WILL BE RETURNED TO YOU
Please scan and save as a .pdf attachment ONLY. We cannot accept other files. Submit
completed form on Moodle. Originals must also be posted in.
Name of Student:_________________________________________________Student ID:________________
Name of Placement Agency (“the Agency”): _____________________________________________________
Dates of Placement: _______________________________________________________________________
Before commencing my placement in the Agency in order to satisfy a compulsory part of the M. Counselling
degree I acknowledge that I understand and fully accept the following:
1. Although the Agency may not be a part of the Faculty of Education, Monash University (“the Faculty”), I have
been accepted as a practicum placement student at the Faculty’s request, to allow me to gain experience in the
normal day-to-day operations of the Agency.
2. While undertaking my practicum placement I will be subject to the rules, regulations and by-laws of the Agency,
and will accept and comply with the Agency’s procedures and the directions of its staff.
3. Any unresolved complaint by the Agency about my actions or standard of conduct during my placement will be
referred as soon as practicable to the Faculty’s course coordinator. The Faculty will investigate the Agency’s
complaint under its applicable statutes and regulations (including the Discipline Statute) and may, if appropriate,
terminate my placement.
4. The Agency has a duty to ensure the safety and well-being of its clients, staff and members of the public on its
premises. If actions of mine prevent or impede the performance of that duty, and immediate notification of the
Faculty is impossible, the Agency may act at once to remove me from its premises, or refuse me admission (as
the case may be). The Agency will notify the Faculty of any such action as soon as practicable, and the Faculty
will investigate the matter as an alleged breach of discipline or act of misconduct under the Discipline Statute, or
take other such action as is appropriate under the statutes and regulations.
Student’s Signature: _________________________________________ Date: ____________________________
Clinical Supervisor’s Full Name (please print): ______________________________________________________
Clinical Supervisor’s Signature:__________________________________________________________________
Agency Representative’s Full Name (please print): __________________________________________________
Agency Representative’s Signature:______________________________________________________________
This information on this form is collected for the primary purpose of obtaining information about the practicum placement you
plan to undertake as part of your degree. Other purposes of collection include attending to administrative matters,
corresponding with you and statistical analyses. If you choose not to complete all the questions on this form it may not be
possible for the Faculty of Education to approve your placement.
Queries are to be directed to your university supervisor or the Professional Experience Office