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PRACTICUM LEARNING CONTRACT

Alcohol and Substance Abuse Counseling

This contract is to be developed by the student and the Agency Practicum Supervisor. It is to be returned to the OSU-Oklahoma City Practicum Instructor BEFORE practicum hours can begin. The signature of both the Agency Supervisor and the student indicate that the contract terms are mutually agreeable and will be followed during the course of the practicum.

Student Name:_________________________________________________________

Beginning Date:________________________________________________________

Approximate Ending Date:________________________________________________

Agency Name & Address:________________________________________________

_____________________________________________________________________

Phone:_______________________________________________________________

Agency Supervisor Name:________________________________________________

Supervisor’s Title:_______________________________________________________

LEARNING OBJECTIVES:

Your learning objectives should be specific statements of what you hope to accomplish during your practicum. These objectives may be academic, personal and/or vocational in nature.

1)____________________________________________________________________

2)____________________________________________________________________

3)____________________________________________________________________

4)____________________________________________________________________

5)____________________________________________________________________

Learning contract

Page 2

PRACTICUM DUTIES AND RESPONSIBILITIES:

Briefly describe:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

ARRANGEMENTS FOR SUPERVISION:

Please indicate frequency and length. (Students are required to meet with the Agency Practicum Supervisor for a minimum of 1 hour for every 20 hours worked. Any exception to this needs to be discussed with the OSU-OKC Practicum Instructor.)

____________________________________________________________________

_____________________________________________________________________

WORK SCHEDULE (be specific - days, times, etc.):

_____________________________________________________________________

_____________________________________________________________________

SIGNATURES:

Agency Supervisor:______________________________________________________

Date:_________________________________________________________________

Student Signature:______________________________________________________

Date:_________________________________________________________________