School and Clinical Child Psychology program
CLINICAL PRACTICUM CONFIRMATION FORM
Director of Clinical Training: Mary Caravias, Ph.D., C. Psych. (Tel: 416-978-0624, Fax: 416-926-4763)
To the student: Complete this form in consultation with your placement supervisor and return to the
Director of Clinical Training before starting your placement.
_____________________________________________________________________________
Student Name: ___________________________________________________________
Email address and telephone number(s):________________________________________
Practicum Guidelines
Practicum Duration:
A standard clinical practicum includes a minimum of 500 hours in a clinic setting, of which a minimum
of 100 hours are face-to-face intervention with clients/patients. Typically, students are in placement two
days each week from September through to May, although placements may extend longer, with the
mutual agreement of the student and supervisor. An additional practicum must be, at minimum, 100
hours in duration and cannot be more than 500 hours. The supervision expectation is one hour for each
day that the student is in the placement. Students undertaking an additional practicum should enroll in
course HDP3243H.
This practicum is a (check one.):
1) standard clinical practicum placement

2) additional practicum placement

Supervision time and evaluation expectations: The practicum supervisor must be a registered
doctoral-level psychologist. It is expected that students receive a minimum of one hour of face-to-face
supervision for each day that they spend in their placement. For a standard clinical practicum, a formal
evaluation of the student’s progress is completed twice during the year. For an additional practicum, at
least one formal evaluation must be completed at the end of the placement.
Activities: Practicum activities should be relevant to the student’s clinical training. Typical activities
include observing assessment and treatment, providing assessment and treatment services under
supervision, report writing, supervision, reading, watching videos, and participating in rounds,
presentations, and team meetings. If time permits, students are encouraged to become involved in
clinical research opportunities.
Liability and Workman’s Safety Insurance Board coverage for the student is not provided by the
University when the student receives remuneration for their work in the placement.
Please indicate (check one): 1) This is an unpaid placement.
2) This is a paid placement.


Practicum Hours
Proposed start date: ___________________
Proposed end date: ____________________
Number of hours per week: _____________
Total number of hours: _________________
Practicum Opportunities
Opportunities for Direct Clinical Service (e.g., individual therapy, group therapy, couple/family
therapy, psychological testing, structured diagnostic interviewing, risk assessments, community
consultation, report writing)
Supervision (please specify frequency and duration of supervision with the primary supervisor
and with any others involved in the student’s training. Please describe specific supervision
activities – for example, individual supervision, group supervision, clinical case review, listening
to audiotaped or videotaped sessions)
Other Opportunities for Clinical Training (e.g., observing assessments, observing treatment
sessions, conducting co-therapy, case presentations, watching training videos, clinical role plays,
learning about ethics and jurisprudence, opportunities to attend rounds, presentations, and team
meetings, clinical readings)
What are the preferred theoretical orientations and models in this placement?
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Updated May 2014
Supervisor Information
* Supervisor Name: ________________________________________________________
* Highest degree earned:
Psy.D. 
Ed.D. 
Ph.D. 
Other  _____________
* Granted at: (Name of University) _____________________________________________
* Current job title:___________________________________________________________
* This information is listed with the SCCP program faculty in the OISE/UT Bulletin under the heading: Adjunct Clinical
Supervisors, in the year following the year of supervision.
Please confirm that you are a registered, doctoral-level, psychologist. Yes 
Phone number: ________________________ Email: ___________________________
Institutional Name: _______________________________________________________
Full Institutional
Mailing Address: ________________________________________________________
________________________________________________________
Honorarium payment procedures:
NB: Honoraria are not paid for additional practicum placements.
 Please donate my honorarium to the SCCP program.
 Please pay the honorarium directly to me, the supervisor.
The honorarium payment is made by July. If the honorarium is to be paid to you, you will be contacted
for DOB and SIN information. Please provide a mailing address:
___________________________________________________________________________
____________________________________________________________________________
Note to the supervisor: We are required to collect CV information from you to conform to CPA
accreditation requirements. You will be contacted separately regarding this.
Signatures: Please sign below to confirm that the above information is accurate. In addition, both
the SCCP student and supervisor acknowledge that Dr. Caravias will be contacting supervisors
periodically to discuss the SCCP student’s progress and to offer recommendations in order to
further develop the student’s clinical needs.
______________________
Student’s signature
_________________________
Supervisor’s signature
______________
Date
Copies of this Form
Supervisors and students are advised to keep copies of this completed form. This original signed form
should be given to Dr. Mary Caravias, C. Psych. (Tel: 416-978-0624, Fax: 416-926-4763)
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Updated May 2014