PROGRAM USE ONLY:
Department of Psychology
MA | PhD Graduate Program
Code: PS __________________
Enrolled Terms: ____________
WSIB Letter on file: _________
Version: August 10, 2015
Clinical Psychology Practicum Agreement Form
Director of Clinical Training: Stephanie Cassin, Ph.D., C.Psych. (stephanie.cassin@psych.ryerson.ca)
Graduate Program Administrator: Tel: 416-979-5000, ext. 2178; E-mail: psychgrad@psych.ryerson.ca
Student Name:
Practicum Course Code:
Supervisor Name:
Date of Agreement:
Practicum Guidelines:
Practicum Duration: Practica must include a minimum of 350 hours each. Typically, practica will not
last more than 500 hours. Practica lasting more than 500 hours require approval from the Director of
Clinical Training. Summer practica typically occur over 4 days per week for 16 weeks (480 hours).
Typical practica during the school year typically occur over 2 days per week, September through April
(480 hours). Students are strongly discouraged from working more than 2 days per week during the
school year.
Supervision: The practicum supervisor must be a registered psychologist. Non-psychologists may also
be involved in the student’s training, but the official supervisor must be a registered psychologist.
Evaluation forms should be completed by the supervisor, with input from others involved in the
student’s training. Students are required to have at least hour-long weekly meetings with their
supervisor.
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.
 Yes | Declaration: By checking this box, I understand that I have WSIB coverage while on unpaid
work placements outside of Ryerson University. WSIB costs are covered by the MTCU, not the placement.
My Student Declaration of Understanding Form is on file in the Psychology Graduate Program Office.
 Not Applicable | Does not apply to any placements at Ryerson including St. Michael’s Hospital Psychology Training Clinic or Ryerson Centre for Student Development and Counselling.
Practicum Hours
Proposed Start Date:
Proposed End Date:
Number of Hours per Week:
Total Number of Hours:
Page 1
Practicum Duties and Responsibilities
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)
Please indicate the primary populations seen at this placement (e.g., ages, diagnostic groups, etc.)
What are the preferred theoretical orientations and models on this placement?
Please indicate the number of different clients the student will likely see during the placement:
Please indicate the anticipated number of direct clinical contact hours during the placement:
Will this practicum placement include opportunities for collaborative research?
No: _____ Yes: _____
Page 2
Supervisor Contact Details
Full Mailing Address:
Telephone:
Fax:
Email:
Supervisor Abbreviated CV
Supervisor: Please complete the abbreviated CV section on the last page of this form. This version is
required for CPA accreditation.
Signatures
Date:
Student’s Signature
Date:
Supervisor’s Signature
Date:
Director of Clinical Training’s Signature
Copies of this Form
Supervisors and students are encouraged to keep copies of this completed form.
This original signed form with WSIB form should be sent to:
MAILING ADDRESS:
IN PERSON DELIVERY:
Graduate Program Administrator
Department of Psychology
Ryerson University
350 Victoria Street
Toronto ON M5B 2K3
Graduate Program Office, JOR-941
Department of Psychology
Ryerson University
380 Victoria Street, Jorgenson Hall
Toronto ON M5B 2K3
Page 3
Abbreviated Curriculum Vitae for Practicum Supervisors
Name:
Highest Degree Earned:
Ph.D. _____ Psy.D. _____ Ed.D. _____ Other _____
Date of Degree:
University Awarding Degree:
CPA/APA Accredited:
No: _____
Yes: _____
Specialty (e.g., Clinical, Counselling, Clinical Neuropsychology):
Internship Completed:
No: _____
Date of Internship:
Yes: _____ (if yes, complete the rest of this section below)
Setting:
CPA/APA Accredited:
No: _____
Yes: _____
Specialty (e.g., Clinical, Counselling, Clinical Neuropsychology):
Registration/Licensure:
No: _____
Yes: _____
Province(s):
Primary Appointment:
Position:
Setting:
Academic Position, Rank, Tenure-Status (if applicable):
Professional Service Delivery (list activities, responsibilities and/or positions):
Professional Honours and Recognition (e.g., Fellow of Professional or Scientific Society; Diplomate):
Member of Professional Societies/Associations (please specify which ones):
PLEASE LIST:
Publications (in last 5 years):
Presentations to Professional or Scientific Groups (in last 5 years):
Funded Research Grants or Training Contracts (in last 5 years; include funding source, duration of
funding, total direct costs):
Other Professional Activities (in last 5 years):
Page 4