MASTER OF COUNSELLING
PLACEMENT COMPLETION SUMMARY FORM
Name of student:
Student ID:
PLACEMENTS COMPLETED
Dates
at
Agency
Placement Settings
Total
hours
completed
Client
contact
hours
completed
Non-contact
Supervision
hours
completed
Noncontact
Other hours
completed
Minimum totals required
280
hours
100
hours
20
hours
160
hours
Totals
I hereby certify that I have completed the hours listed above. All entries in the logs I have maintained
for placement have been checked and certified by supervisors.
(False declaration is a reportable offence)
Student signature…………………………………..……………
Date ………….
The information on this form is collected for the primary purpose of evaluating the practicum placement the student has undertaken as part of their 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 provide a result for the student’s placement. You have a right to access personal information that
Monash University holds about you, subject to any exceptions in relevant legislation. If you wish to seek access to your personal information or inquire about the
handling of your personal information, please contact the University Privacy Officer on 9905 6011.
February 2016