Intern Questionnaire Name* First Last Date* Date Format: MM slash DD slash YYYY Questions for Prospective Internship/Practicum StudentsWhich program are you in and where?Where are you at in that program? I.E.: estimated graduation dateWould this be considered an official internship or a practicum?What type of qualifications must your site supervisor have?What is the start date for your practicum/internship?How many hours do you need? Weekly, Semester, direct and indirectWhat is your availability- do you need to be on site during the day, evenings, Saturdays?Is it required for you have independent hours seeing clients by yourself or to just observe with a qualified clinician?What days and hours would you be available?The more flexibility you have, the better we can provide you with clients. We require the availability to see at least 8-10 clients a week (unless you are only observing). We also prefer to be your only internship site for the period you are here.MonTuesWedThursFriSat What clients do you feel comfortable seeing? Type of issues?Do you have experience providing counseling?Do you need individual supervision, or is that covered by the program?Do you need individual supervision, or is that covered by the program?Would a group supervision with other interns be enough to meet your requirements?If not, how often would you need supervision here?If you are required to facilitate the sessions, do you have liability insurance? If not, are you willing to get it?Does your internship/practicum course supply paperwork to you for weekly logs of hours, supervisor/site feedback, consent for observation etc. Are you required to keep track of these forms yourself or does it need to be supplied by the site?NameThis field is for validation purposes and should be left unchanged.