Agency Information Form

Agency Information Form

To be completed upon acceptance to an agency for field practicum
IMPORTANT:

Prior to completing this form, the student must have contacted the agency and have a firm preliminary acceptance to intern with that agency for 2 semesters and also have a field practicum supervisor with the required credentials.

If you are an Advanced-Standing student, please inform your assigned field internship coordinator, as soon as possible, if the agency you are submitting is the same agency you interned at for your BSW practicums. Further instruction will be given regarding submitting a "Petition for Same Agency" form that must be approved by the MSW Field Director in order to proceed with this agency.

WNMU School of Social Work will contact the agency using the information you have provided below; however, it is the student's responsibility to follow up to ensure that all agency forms are submitted and complete prior to beginning an internship. To follow up, contact your School of Social Work Internship Coordinator.
Name*

First NameLast Name
W#*
WNMU Student ID
Field Practicum Course*
Semester requested*
Year Requested*

Agency Name*
Accepting Agency Name
Agency Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agency Website*

No Website availableOther
Legal Representative Contact is the authorized person at the agency who will be responsible for completing the WNMU Affiliation Agreement, since this is a legal contract between the agency and WNMU. Please reach out to the agency to obtain the contact information of who this representative should be.
Field Agency Legal Representative Contact*

First NameLast Name
Title*
Job Title (e.g. Director)
Field Agency Legal Representative Contact Email*
example@example.com
Field Agency Legal Representative Contact Phone Number*

Area CodePhone Number

Field Agency Supervisor must be employed or contracted with the agency, completes a student intern's mid-term and final evaluations, receives and reviews timesheets via Qualtrics, provides supervision (when applicable), and signs completed Learning Contract. This person may be the same as the Agency Contact. If so, please re-enter the information.
Students are required to have a field practicum agency supervisor, who is employed or contracted with the agency, and who is an MSW or LCSW with at least 2 years of post MSW practice experience.

In rare instances (i.e. provider shortages), a student may request approval for their agency supervisor be credentialed with a Master’s degree in a related field (such as counseling or psychology). This task supervisor will need the approval of the MSW and/or BSW Field Director.

Approval for such a request is not guaranteed. If approved, the student is required to enroll in SWK 583 or SWK 497 as well as their practicum course, to comply with the WNMU School of Social Work and applicable licensure requirements.
Field Agency Supervisor *

First NameLast Name
Title*
Job Title (e.g. Director)
Field Agency Supervisor Email*
example@example.com
Field Agency Supervisor Phone Number*

Area CodePhone Number
Is the Agency Supervisor employed or contracted with the Agency?*

EmployedContractedNot Employed with the Agency
Field Agency Supervisor is an :*

MSW/LMSWLCSW/LISWOther "Related Field"
If you selected "Other Related Field", please provide what type of Masters Degree your field practicum agency supervisor has:*

Not ApplicableOther