Adams State University School of Counselor Education - Practicum Supervisor Agreement for Fall 2025
 
Supervisors - Please fully complete this form with your supervisee. 
The form must be submitted using the student's ASU email address.
Email *
Student Last Name:   *
Student First Name *
Student ID # *
Adams State University Student Email Address:  
 *
Cohort *
Semester/Year of Practicum  *
Pre-requisite Information *
By the time you begin Practicum, will you have completed the following prerequisites? (check all that apply). You cannot enroll in Practicum if you haven’t completed the required courses below. 
Required
Student liability insurance expiration date *Students are responsible for maintaining liability insurance and uploading proof of insurance into Blackboard during Pre-Practicum, Practicum, Internship I, and Internship II.
 *
MM
/
DD
/
YYYY
Specialty for Practicum *
Required
Are you a dual student?
 *
Name of Site *
Site Website *
Is your site a Physical Site, Telehealth Site, or Both? *
Required
Types of services provided to clients/students at site *
Tentative duties for practicum student:  *
Is the student currently employed at this site?
 *
*If yes, please describe the new duties the student will be assuming for their practicum experience.  Students should look at the clinical experience as an opportunity to further develop and enhance their counseling skills. Students employed at sites longer than six months and/or doing professional work other than counseling (e.g., case management, casework, school aide) are required to seek out new opportunities at their employment site in consultation with their site supervisor.
Site Supervisor: Name (NAME in which you hold your professional license) *
Site Supervisor Email Address

 *
Site Supervisor Phone Number *
Physical Address and City Site is Located (e.g., 208 Edgemont Blvd. Alamosa) *
State Site is Located *
Highest degree earned for site supervisor (MA or PhD) *
M.A. Degree Concentration (e.g., Counseling, Psychology, Social Work, School Counseling, etc.)  *
Year Degree Awarded *
Professional counseling licenses and/or certifications and numbers & 
expiration date of license   (e.g., LPC #1234, etc., School Counseling License #1234)
 *
Are you qualified to provide counseling AND supervision in your state? Yes or No? If not, please explain *
Number of years as a licensed counselor, post-master’s degree, in the specialization
(School Counseling or Clinical Mental Health Counseling): *
Number of years providing supervision. *
The ASU Counselor Education Program Faculty provides all site supervisors with online supervisor training aimed at orienting them to the ASU expectations, requirements, and evaluation procedures for students. 
Have you reviewed the online information? 
*If no, please complete the ASU training provided:  https://www.adams.edu/academics/graduate/counselor-education/masters/supervisor-training/
 *
Required
Type(s) of Relevant Training in Counseling Supervision:
What type(s) of relevant training have you, the supervisor, received in counseling supervision (training that includes an understanding of models and theories of counseling supervision, ethical issues relevant to counseling supervision, and multicultural issues relevant to counseling supervision)? Speak to any training in technology utilized in counseling supervision.

*If you have not completed training in counseling supervision, you must complete the ASU training provided: https://www.adams.edu/academics/graduate/counselor-education/masters/supervisor-training/
 *
Has the supervisor received disciplinary action from their state regulatory agency and/or department of education?
*If yes, please provide a summary of the disciplinary action
 *
Is the site supervisor on-site or off-site? *
Required
If the Site Supervisor is Off-Site:
Please list the following contact information of the on-site person: 

Contact person

Title/Role

Email address

Phone number

 *
In the Case of an Emergency at the site, what will be the procedures of the Practicum Student? Who will they contact at the site, and how?   *
Contract, Schedule & Agreement Statements
The purpose of this agreement is to provide the Practicum Student with a Practicum Experience in the field of professional counseling, to ensure the welfare of clients/students seen by the practicum student, and to promote the development of the practicum student's professional counselor identity and competence. The practicum experience must be reflective of a clinical mental health or professional school counselor, with an emphasis on practicing foundational and advanced counseling skills (e.g., demonstrating empathy, reflecting meaning, reframing, etc.). A minimum of 100 clock hours are required over the course of the academic term, with at least 40 clock hours in direct service with clients/students. 
The agreement will remain in effect for:
This agreement will remain in effect for the duration of the Practicum Student’s Practicum Experience. Termination of this agreement prior to the completion of the Practicum Experience requires the consultation of the Clinical Coordinator, Faculty Supervisor, Site Supervisor, and Practicum Student.
PRACTICUM ROLES AND RESPONSIBILITIES FOR FACULTY SUPERVISOR, SITE SUPERVISOR, AND PRACTICUM STUDENT 
THE ROLE OF THE FACULTY SUPERVISOR:
- Provide a minimum of 1.5 hours/week of group supervision to the practicum student enrolled in the course section
- Provide regular, formative feedback to the practicum student
- Consultation between the Counselor Education program to monitor student learning will occur a minimum of five times per academic term utilizing email and/or phone contact as well as substantive evaluation form completion.
-To notify the student that he or she must adhere to the administrative policies, rules, standards, schedules, and practices of the Site; 
- Be reasonably available to meet with the practicum student (one-on-one) to address questions, concerns, and provide support (as requested by the practicum student)
- Verify completion of required documents for the practicum experience 
- Assign the final practicum course grade with consideration of feedback from the Site Supervisor and instructor(s) of the Lab portion of the course 
- Consult with the faculty of the School of Counselor Education at Adams State University regarding concerns related to the practicum student's skills, knowledge, and professional dispositions.

THE SITE SUPERVISOR AGREES TO THE FOLLOWING: 
- Hold a minimum of a master’s degree, preferably in counseling, or a related profession (e.g. Social Work, Marriage and Family Therapy, Psychology, etc.)
- Hold relevant certifications and/or licenses. All supervisors must be licensed within the discipline they are working in, e.g. Licensed Professional Counselor, Licensed School Counselor, Licensed Marriage and Family Therapist, Licensed Clinical Social Worker, Licensed Addictions Counselor, Licensed Psychologist, etc.
- School Counseling site supervisors MUST be a Licensed School Counselor or state equivalent
-Provide a confidential space for students to engage in appropriate practices with appropriate supplies and supports (phone, computer, office supplies, staff, etc.).
- Provide supervision through cyber-secure video or audio recordings, with appropriate approvals from clients/students or guardians, of the practicum student's interactions with clients/students. If not video or audio recordings, the supervisor will offer live supervision to the practicum student.
- Teach the practicum student about the technological resources available at the site and ethical use.
- Provide appropriate professional experiences for the practicum student, involve the practicum student in a range of meetings, resources, and activities at the site, and allow the practicum student opportunities to collaborate with or observe other professional counselors.
- Create a supportive atmosphere where the practicum student can be open about the challenges they face.
- formally and informally evaluate the practicum student on a regular basis by observing counseling skills, discussing progress, and providing feedback.
- Provide direct (virtual or in-person) individual (one supervisor to one student) or triadic (one supervisor to two students) supervision for a minimum of one hour per week to the practicum student throughout the entire term.
- Consult with the Faculty Supervisor if experiencing concern regarding the practicum student's counseling skills, knowledge, or professional dispositions with appropriate documentation.
- Understand Adams State University does not take responsibility for students at the practicum sites outside of the academic term in which students are enrolled in practicum and practicum courses. 
- Understand the practicum student is not required by the program and is generally discouraged from remaining at site(s) during breaks and/or terms outside of enrollment in the practicum course.
- Take complete legal and professional liability as it relates to the practicum student meeting with clients/students outside of the academic term of the practicum course in which the practicum student is enrolled. 
- Maintain continuity of care of clients/students seen by the practicum student outside of the academic term.
- Assume legal responsibility for the welfare of clients/students seen by the practicum student as part of the practicum experience.
- Promptly alert the Faculty Supervisor of any unethical or problematic student conduct with appropriate documentation.
- Review, complete, and approve the practicum student's hour logs and required documentation in a timely manner.

THE PRACTICUM STUDENT AGREES TO: 
- Conduct and identify self as a professional counseling practicum student.
- Follow the American Counseling Association Code of Ethics and the American School Counselor Association Ethical Standards for School Counselors (School Counseling specialty) or American Mental Health Counselors Association Code of Ethics (Clinical Mental Health Counseling specialty).
- Adhere to administrative policies, rules, standards, and practices of the practicum Site and the School of Counselor Education at Adams State University per the Clinical Manual and M.A. Student Handbook.
- Keep the Faculty Supervisor and Site Supervisor informed regarding practicum experiences.
- Demonstrate the minimum level of competency in counseling knowledge, skills, and professional dispositions in order to receive a passing grade in the practicum course.
- Engage in the required average one hour individual or triadic and one-and-a-half hour group supervision each week of the practicum experience throughout the entire term.
- Maintain their commitment to the approved site throughout the entire academic term by engaging in the accruing of hours each week.
- Complete all documentation as required by the approved site and Adams State University.
- Maintain counseling student liability insurance coverage throughout the practicum experience.
- Perform a variety of counseling activities under the supervision of the approved Site Supervisor.
- Follow the practicum course syllabus for course requirements. Practicum students are expected to inform site supervisors of required course assignments and deadlines in a timely manner (i.e., recording/live supervision form, midterm and final evaluation forms, etc.).
- Comply with any other requests of the Approved Site, such as completing HIPAA training, background checks, or drug testing.
- Communicate with the Faculty Supervisor and Clinical Coordinator if there are any changes to the Approved Site or Site Supervisor.
- Contact and consult with the Site Supervisor in case of emergency.
THE UNIVERSITY AGREES TO: 
- Provide students who are not receiving payment of any form with coverage under the Colorado Workers' Compensation Act [more information can be provided in section 8-40-302, sub-section (7)(a), and (b)].
-To assign a Faculty Instructor to facilitate communication between the University and the Site;
STUDENT:
By typing my name and date, I agree to the expectations outlined above and will adhere to the policies and procedures described throughout the Practicum Experience. I agree to conduct professional behavior according to the ethical principles of our professional associations. 
 *
SITE SUPERVISOR:
Semester dates: 
Practicum: August 18, 2025 through December 12, 2025
 *
Required
SITE SUPERVISOR: 
 SITE SUPERVISOR TELEHEALTH Acknowledgement:
Site supervisor is trained to provide telehealth services. Additionally, the site supervisor agrees to train the student to facilitate telehealth sessions when appropriate.
 *
Required
SITE SUPERVISOR STUDENT VERIFICATION Acknowledgement:
By typing my name and date, I verify that I have seen this student's ASU ID or State-issued ID and have verified this is the above-mentioned student. I agree to the expectations outlined above and will adhere to the policies and procedures described throughout the Practicum Experience. I agree to engage in professional behavior according to the ethical principles of our professional associations. 
 *
SITE SUPERVISOR ACADEMIC TERM Acknowledgement: 
By checking the box, I acknowledge that if the site or supervisor requests the student to remain at the site beyond the Adams State University Practicum term, the site and supervisor assume full legal and professional liability for the student’s activities during this time. The student may not identify as an ASU Practicum student, will not be supervised by ASU Counselor Education faculty, and cannot accrue Practicum hours. Both the student and supervisor are responsible for securing liability insurance coverage for any activities outside the academic term of the Practicum course.
 *
Required
SITE SUPERVISOR DATABASE Acknowledgement: 
By typing name and date, the Site and Site Supervisor will be automatically added to our database for future students to review. Please email the Clinical Coordinator at counseloredcc@adams.edu if you wish to have your site or name removed from this database. 
 *
A copy of your responses will be emailed to .
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Adams State University.

Does this form look suspicious? Report

Google Forms