Field Placement Site Tracking Survey

Field Placement Tracking Survey

The purpose of this survey is to systematically collect field placement data (Practicum, Internship 1, and internship 2) from Counseling Students each semester. Students are required to complete this form EACH semester that they are enrolled in Practicum, Internship 1 or Internship 2 - even if they are staying at the same site. This will allow us to keep a comprehensive database of student placements, which will facilitate supervisor contact and smoother placements for future students.

Please be sure that all information you enter is ACCURATE. If you are unsure of any information, please wait until you have collected all proper contact information before completing the survey. If you have any questions about the survey, please contact Dr. Robertson. Thank you!

Heather Robertson, PhD, NCC, CRC, LPC
Associate Professor, Counselor Education Programs
St. John's University, School of Education, Sullivan Hall, G-06
(718) 990-2108, robertsh@stjohns.edu

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* 1. Please enter your contact information (student).

Name

Email Address

Phone Number

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* 2. What program are you enrolled in?

MSEd in School Counseling

MSEd in School Counseling with Bilingual Extension

MSEd in Clinical Mental Health Counseling

Advanced Certificate in School Counseling

Advanced Certificate in Clinical Mental Health Counseling

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* 3. Please enter the current year that you are enrolled in (e.g. 2015, 2016, etc.).

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* 4. Which semester are you entering data for?

Spring

Fall

Summer

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* 5. Which field course are you enrolled in this semester?

Practicum

Internship 1

Internship 2

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* 6. On which campus are you enrolled in your field placement course?

Queens

Staten Island

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* 7. Please enter your field placement site and field placement site supervisor information.

Supervisor Name *

Field Placement Site *

Address

Address 2

City/Town *

State/Province *

ZIP/Postal Code

Supervisor Email Address *

Supervisor Phone Number

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* 8. Mental Health Counseling Students Only: What credential does your supervisor hold?

LMHC

LCSW

Licensed Psychologist

Licensed Psychiatrist

Licensed Psychiatric Nurse Practitioner

Other (please specify)

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* 9. Mental Health Counseling Students Only: Is the supervisor you listed the same contact that you used to obtain your ifoield placement?

Yes: This is the person I contacted to obtain the field placement.

No: I contacted another individual/office and I was placed with this person.

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* 1. Please enter your contact information (student).

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* 2. What program are you enrolled in?

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* 3. Please enter the current year that you are enrolled in (e.g. 2015, 2016, etc.).

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* 4. Which semester are you entering data for?

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* 5. Which field course are you enrolled in this semester?

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* 6. On which campus are you enrolled in your field placement course?

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* 7. Please enter your field placement site and field placement site supervisor information.

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* 8. Mental Health Counseling Students Only: What credential does your supervisor hold?

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* 9. Mental Health Counseling Students Only: Is the supervisor you listed the same contact that you used to obtain your ifoield placement?

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* 10. If you answered "NO" to the question above, please provide the name and contact phone number that you utilized to obtain your placement.