COLLEGE OF HEALTH & SOCIAL SCIENCES
DEPARTMENT OF COUNSELING
1600 Holloway Avenue, Burk Hall 524
San Francisco, CA 94132
Tel: 415/338-2005
Fax: 415/338-0594
FIELD PLACEMENT APPLICATION
College/ Career Counseling
Date_______________
Name of Placement:
Phone Number:
FAX Number:
Location:
Number and Street
City, St
Zip
Number and Street
City, St
Zip
Number and Street
City, St
Zip
Additional Location:
Mailing Address:
Trainee Coordinator:
Phone Number:
E-Mail:
San Francisco State University, Department of Counseling is committed to equal access for all students. Placement
sites must be willing to accommodate students with disabilities, if students can perform the essential functions of the
job, and if accommodations requested are reasonable.
Yes 
Yes 
Is this agency willing to accommodate students with disabilities?
Is this agency wheelchair accessible?
No 
No 
Description of Services provided & population served:
Counseling Services:
Individual Family -
Age Range of Clients:
Yes  No 
Yes  No 
0-11  12-18 
Group Yes  No 
Workshops Yes  No 
Adults  Seniors 
Ethnicity of Client Population: Please describe using approximate %.
Type of Supervision**:
Degree (M.A., Ph.D.), Certification (e.g. CRC) held by supervisor/s:
License held by supervisor:
Supervision:
 - Individual: 1 Hour/Week Required
 - Group:
Methods of Supervision:  Case Presentation
No. of Hours Provided:
No. of Hours Provided:
 One-Way Mirror
 Video Taping
 Audio Recording Required  Process/Progress Notes  Role Play
.
Attach extra pages with additional information or comments
Field Placement Application: February 5, 2016
Audio recordings of trainee interviews with clients are required by this Department. Students are required to play
recordings to faculty supervisors. Second year interns are required to have recorded sessions available for faculty
supervisor by October 15.
Is recording of interviews allowed by your agency with permission from clients?  Yes  No
Will second-year interns be able to have substantive recorded counseling sessions with clients by October 15? 
Yes  No
Responsibilities of Trainee: Please describe the fieldwork experience and responsibilities the trainee will have at
your agency. Please attach a copy of description of trainee duties provided to trainees.
Type of Counseling that Trainee will Provide*:
Number of client hours per week the trainees are assigned:
(A minimum of 2 and maximum of 8
clients are required for 1st yr. trainees and a minimum of 5 and maximum of 12 clients for 2nd yr. trainees.)
Do you have a didactic training component as a part of your program?  Yes
Please describe:
 No
EMPLOYMENT STATUS OF TRAINEE:
 - Volunteer
 - W-2 Employee
Rate of Pay $
 - Stipend
Amount $
Number of Hours Per Week Required of Trainee:_____________
Period of Traineeship: From ____________ To _____________
What is your Trainee application process?
Mandatory Time Commitments: (please include as much information as possible, including day, week and time
of staff meetings, trainings, etc., if applicable.)
.
Attach extra pages with additional information or comments
Field Placement Application: February 5, 2016
Emergency Protocol for Intern Safety and Client Risk Assessment:
a. Please describe protocol to ensure student safety (please be as specific as possible including instructions given to
intern, person in charge when supervisor is unavailable, etc. Attach sheet if helpful):
b. Please describe protocol for client/student risk assessment in your setting and ways in which intern will be
supported should that situation arise (please be as specific as possible including instructions given to intern, scope of
responsibility, person in charge if supervisor is unavailable, etc. Our expectation is that students will be supported
in assessing risk to the degree appropriate to the setting and, at the very least, will receive supervision on triage
responsibilities to assess the urgency of referral and referral process appropriate to the situation. Attach additional
sheet if helpful):
*Type of counseling provided by intern should be “substantive counseling” content. In other words, interns must be
able to engage with students/clients in a way that addresses life issues, family issues, inter and intra personal issues.
Counseling should call on intern to use of basic and advanced listening and engagement skills, facilitating client in
greater self-understanding within a cultural context as well as help clients define the concern as well as identify
pertinent influences, and potential avenues for addressing concerns. Although we understand that some sessions may
reflect information giving or transactional interactions, this should reflect only a small portion of the sessions interns
engage in as they are not sufficient for developing the counseling skills needed for the internship experience.
** The relationship between the supervisor and intern must be a singular role of that of a clinical supervisor. In the
rare occasion where the intern has a pre-existing relationship, the intern must be supervised by someone who has not
had a previous relationship (and does not currently have a relationship) with the intern other than that of a clinical
supervision relationship, unless a sufficient period of time has passed to render issues of dual relationship inert (2
years based on ACA ethical guidelines). If on the rare occasion a student has received permission from the
Department of Counseling to engage in an internship in their worksite or in a student service unit in which the intern
has, or continues to, receive services, there must be a clear separation of roles of the supervisor and intern vs. service
provider and consumer or administrative supervisor and employee.
The program is committed to a culture that is inclusive of, but not limited to, ethnicity, race, gender, sexual identity
sexual orientation, religion, socioeconomic status, national origin, disability, age, and indigenous status. Therefore,
we encourage supervisors from all cultural backgrounds to work with our diverse students.
.
Attach extra pages with additional information or comments
Field Placement Application: February 5, 2016