Department of Counseling, Administration, Supervision & Adult Learning
College of Education
CLINICAL MENTAL HEALTH COUNSELING
INTERNSHIP LEARNING CONTRACT
Intern’s Name
CSU ID #
Intern’s Address
_
Zip
Intern’s Phone Number
Cell
Intern’ Email
Supervisor’s Name
Supervisor’s Title
License
Supervisor’s Phone
Phone #2
Supervisor’s Email
Placement Name
Placement Address
Zip
INTERNSHIP SITE/SUPERVISOR AGREEMENT:
I. The internship site will provide counseling services, including the diagnosis and
treatment of mental/emotional disorders.
II. Students will be afforded a 32 week internship during the academic year (AugustMay).
III. Interns will be afforded a minimum of 600 internship hours. At least 40% of the
hours will be in direct service (providing assistance to client/s in the form of
individual counseling, group counseling, family/couples counseling, assessment,
or psycho-educational initiatives aimed at remediating difficulties or facilitating
personal growth).
CMHC Learning Contract / Revised 2015
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IV. The remaining internship hours will consist of individual supervision (on site),
group instruction (CSU), providing clinical hours in the Counseling and
Academic Success Clinic (CASC) under the direction of the faculty in the
Counseling program at CSU, the preparation of treatment plans, completion of
paperwork, staff/educational programming (e.g. grand rounds, in-service
programs, etc.), case conferences, etc. Research, clerical, and administrative
functions do not qualify as internship hours.
V. A minimum of 35 hours of individual, face-to-face supervision (on site) will be
provided the counselor trainee during the course of the internship. This
approximates one hour per week. This supervision will be provided by a
Professional Clinical Counselor with supervision endorsement (PCC-s) in keeping
with standards of the State of Ohio Counselor, Social Worker, and Marriage &
Family Therapist Board.
VI. The internship site will authorize the audio and/or video taping of most individual
counseling sessions. The tapes are used to evaluate the intern and to help him/her
develop counseling skills. Tapes will be reviewed by the CSU faculty and may
also be viewed during group instruction. The identities of the clients will at no
time be compromised and all recordings will be erased after supervisory review.
Clients will be asked to sign a release authorizing the intern to tape their sessions.
If the site does not have a release form for such taping, a sample form will be
provided by the Counselor Education program at Cleveland State University.
VII. The on-site supervisor agrees to meet with the CSU faculty and intern during each
semester of the internship. In addition, the supervisor will complete the following
documentation as required by the State of Ohio Counselor, Social Worker, and
Marriage & Family Therapist Board and/or by Cleveland State University:
Supervision Agreement
Evaluation and Verification of Supervised Experience
Documentation of Hours
Intern Evaluations
For Site Supervisor Only:
Please list any relevant training and/or continuing education* you have received in the past
two years regarding counselor supervision:
* If you haven’t receive any training specific to counselor supervision in the past two years,
you can register for a free continuing education workshop for Counselor Supervision
through the Continuing Education Program at Cleveland State University. For further
information, please contact the Continuing Education Coordinator, Noelle Muscatello, at
216-687-3867 or cecasal@csuohio.edu. You can also visit the website at:
http://www.campusce.net/csucasal/category/category.aspx?C=&S=47
CMHC Learning Contract / Revised 2015
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I agree that the Internship will meet or exceed the identified requirements. I
understand that these requirements meet the guidelines as mandated by the State of
Ohio Counselor, Social Worker, and Marriage & Family Therapist Board and the
guidelines of the Council on Accreditation of Counseling and Related Educational
Programs as adopted by the Counselor Education program at Cleveland State
University. In addition, I will assist the Counselor Trainee in securing competence in
the provision of counseling services as outlined by the Intern Agreement in this
Learning Contract.
Supervisor’s Signature
CMHC Learning Contract / Revised 2015
Date
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INTERN AGREEMENT:
I. Orientation toward and the competent administration of Intake Interviews, as consistent
with the Internship site protocol, including Mental Status Examination, structured or
semi-structured interview, or other assessment measures and forms.
II. Orientation toward and adequate preparation of treatment plans as dictated by the
administrative procedures of the site and the population served.
III. Orientation to and demonstration of competence in the diagnosis of mental or emotional
disorders in a diverse group of clients.
IV. Orientation to and demonstration of competence in the treatment of mental or emotional
disorders in a diverse group of clients.
V. Demonstration of cultural awareness, adaptation to, and sensitivity toward diverse client
populations (e.g. racial or ethnic minorities, women, elderly persons,
physically/intellectually challenged, gay men/lesbians/bisexuals, economically
marginalized individuals, etc.).
VI. Cogent and accurate record keeping in accord with the ethical guidelines of the American
Counseling Association, legal requirements of the State of Ohio, and the mandates of the
internship site.
VII. Demonstration of appropriate interpersonal skills during counseling sessions and in
contact with supervisors, staff, and other professional contacts directly associated with
the counseling internship.
I agree to secure competence in the provision of counseling services, as defined in the Intern
Agreement portion of this Learning Contract. In addition, I will collaborate with the
Internship Supervisor in meeting the requirements as set forth by the Internship
Site/Supervisor portion of this Learning Contract.
Intern’s Signature
_ Date
Agency Counselor Internship Contract/rev. 2015
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