College of Health & Human Services
Department of Counseling
(415) 338-2005
(415) 338-0594 Fax
San Francisco State University
1600 Holloway Avenue, BH 524
San Francisco, California 94132
FIELD PLACEMENT APPLICATION
Gerontological 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:
CounselingServices:
Age Range of Clients:
F
ebruay16,20
Individual
Family
0-11 
Yes  No 
Yes  No 
12-18 
Adults 
Group
Workshops
Seniors 
Ethnicity of Client Population. Please describe using approximate %.
.
Attach extra pages with additional information or comments
Field Placement Application:
Yes  No 
Yes  No 
Type Of Supervision
Degree (M.A., Ph.D.), Certification (e.g., CRC ) held by supervisor/s:
Supervision:
 - Individual: 1 Hour/Week Required
No. of Hours Provided:
 - Group:
No. of Hours Provided:
Methods of Supervision:
 Case Presentation
 One-Way Mirror
 Video Taping
 Audio Recording Required  Process/Progress Notes  Role Play
Tape recordings of trainee interviews with clients are required by this Department. Students are required to play
tapes to faculty supervisors.
Is taping of interviews allowed by your agency with permission from clients?  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. If duties will be performed
off site please explain emergency contact procedures.
Number of client hours per week the trainees are assigned:
(A minimum of 2 clients and maximum of 8 clients is required for 1st yr. trainees and a minimum of 5, maximum of
12 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.)
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 16, 2016