LEARNING CONTRACT

You will complete two learning contracts throughout your clinical experience at Wheaton College. One will be your practicum so please only select the practicum box below and indicate the dates of your practicum placement (start date through 10 weeks). Your second learning contract will be due at the beginning of your internship. For this internship learning contract please select only the internship box below and the dates of placement will be: first day of internship - end of your site contract.

[Completed by Student & Site Supervisor (please select only one at a time)]*

PracticumInternship

Training Semester(s):*

Student:*

Student Email:*

example@example.com

Site:*

Site Supervisor Name:*

Site Supervisor Email:*

example@example.com

Site Supervisor Graduate Degree(s) Obtained:*

License/Certification:*

License #:*

Profession (i.e. LCPC, LCSW, Psychologist, etc.):*

Held License Since:*

License Expiration Date*

Contact Phone Number:*

Additional Site Supervisor (if different from Clinical Supervisor):

Site:

Site Supervisor Graduate Degree(s) Obtained:

License/Certification:

License Number:

Profession (i.e. LCPC, LCSW, Psychologist, etc.):

Held License Since:

License Expiration Date

Additional Site Supervisor Email:

Contact Phone Number:

Clinical Supervisors of Master’s students must be appropriately licensed masters, or doctoral, level clinicians (LCPC, LCSW, licensed PhD, licensed PsyD)

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Additional student comments:

Additional supervisor comments:

Outline of required training hours & responsibilities:

CMHC Practicum – Minimum 100 hours, 1 semester in duration A minimum of 40 hours of the student’s activities/hours must involve face-to-face direct service.

CMHC Internship - Minimum 600 hours, 2 semesters in duration A minimum of 240 hours of the student’s activities/hours must involve face-to-face direct service. All internship students must gain some experience leading groups.

1. Placement will begin:

Date

and go through:

Date

2. Hours / Days / Week to work:

3. Practice Activities by hours or #s per week or month as applicable (approx):

a. Counseling cases per week:

b. Intake sessions per week:

c. Diagnostic evaluations per week:

d. Professional presentations per week:

e. Research activities per week:

f. Group experience per week:

g. Other (community intervention, advocacy) per week:

*Please specify the details of above practice activities here:

4. Time off allowed:

a. Holidays:

b. Vacation:

c. Sick Days:

5. Practice supervision and training:

a. Individual supervision per week:

b. Group supervision per week:

c. Live supervision per week:

d. Case conferences per week:

e. Seminars peer week:

f. Staff meetings per week:

g. Other training per week:

A Licensed Site Supervisor will provide a minimum of 1 hour, weekly, continuous individual supervision.

Live supervision refers to direct observation of a clinical practice or may consist of reviewing an audio or video recording.

Some level of live supervision is required, with regular live supervision preferred.

6. Accruing hours during semester breaks

Please specify any semester breaks that a student is expected to continue clinical training:

a. Winter Break (e.g., December/Jan January):

b. August Break:

During semester breaks, students may continue to continue to accrue hours if they are receiving a minimum of one hour per week of individual supervision by their Site Supervisor, if the student has completed and submitted the Between Semester Supervision Notification form (end of contract) to the designated On-Call Faculty Supervisor.

7. Recorded Client Sessions

On a regular and selective basis, with the informed consent of the client or guardian, and with the approval of the site supervisor, the student will be allowed to present client audio or video recordings to CMHC faculty supervisors and during class group supervision, for purposes of professional training and examination. The site will provide recording consents that students are to use, and these consents will be maintained client in the client documentation at the site. The site will determine the process for obtaining the recording informed consent.

Wheaton College has a Business Associates Agreement (BAA) with Microsoft that covers Teams, which allows the use of Teams for HIPAA-covered tele-medicine or tele-counseling. Students will record and store either audio or video sessions on Teams in a folder for designated for the student and the faculty supervisor on Teams. If there is no ethical or legal mandate to keep the recording after playing the recording during supervision, each student is required to delete the recording on Teams.

Confidentiality of written case reports will be protected by not including names (clients), or dates of birth, and these case reports will be shredded after case presentations are completed.

*If the site does not permit recording sessions, Site Supervisors are required to observe a live counseling session and complete a Site Supervisor Live Observation Evaluation, in lieu of recording.

List site stipulations regarding case material:

Documents to be completed during the training period:

Learning Contract: To be completed by the student and the Site Supervisor within the first two weeks of beginning the training at the site.
Student Evaluation: To be completed by the Site Supervisor at the end of the Practicum semester and the end of each semester of Internship. The form should be provided to the supervisor by the student, but may be accessed via the Site Supervisor Manual.
Hour Log: To be completed by the student at the end of each semester of clinical training (Practicum and Internship) and signed by the Site Supervisor, Faculty Supervisor, and student verifying the student’s training experience.

For the student to read before signing below:

The information recorded above is correct to the best of my knowledge. I will endeavor to uphold this contract through the training experience.

Changes in the contract prior to or during the that it is in effect can be made if agreed upon by all parties. All changes should be made in writing on or attached to the original contracts, initialed, and resubmitted to the Office Training Coordinator.

By signing below, I understand that I am training under my Site Supervisor’s license. I will act in compliance with the ACA Code of Ethics, including accurately recording all practicum/internship hours and activities, accurately maintaining clinical records, and acting under the guiding principles of beneficence and nonmaleficence. Additionally, when I am unsure of my ethical and professional responsibilities, I will communicate my concerns to my supervisors and my academic training department, always practicing good judgment and consulting as needed.

Student signature:

Date

For ths Site Supervisor to read before signing below:

By signing below, I agree that I am a licensed mental health professional and that the student’s experience will be performed under my direction and professional responsibility as a supervisor. As a supervising clinician, I will adhere to the ACA Code of Ethics and agree that the above stated clinical activities are within my competence to supervise. Additionally, I agree to discuss concerns about the student’s performance with the student and with the student’s academic training department, if indicated. If a student is not meeting expectations, I agree to attempt remediation with the student prior to termination. I understand that terminating a student from placement during the training experience should occur only with proper notice and following an appropriate course of action focused toward attempting to resolve the situation. Immediate termination is warranted only in rare cases of severe ethical violation.

Site Supervisor Signature:

Date

*Please make sure you download copies of this contract when it is completed and signed.

Student Name:

Student Cell Phone Number:

Practicum/Internship Site:

Site Supervisor Name:

Site Supervisor Phone Number:

Site Supervisor Email:

example@example.com

For the student to read before signing:

By signing this form, if I continue to be at my site during semester break during department accepted dates (i.e., month of August, Christmas break, spring break, May break), I will continue to receive individual supervision from my Site Supervisor for a minimum of one hour per week. Additionally, my signature indicates that I agree to contact the On-Call Faculty Supervisor for supervision on an as needed basis. I understand that between semesters, my Site Supervisor primarily provides supervision; however, the On-Call Faculty Supervisor is available to me as needed. I understand that I must continue to log my hours on the Hour Log and keep copies of all supporting documentation. I agree to keep the On-Call Faculty Supervisor apprised of any ethical, legal, or crisis situation during the break.

STUDENT SIGNATURE

DATE

Date

SITE SUPERVISOR SIGNATURE

Date

LEARNING CONTRACT

Clinical Mental Health Counseling Program

Supervisor Criteria:

Preliminary Learning Objectives:

Between Semester Supervision Notification Form