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EP Program
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Enhanced Placement
Program Please complete this form by checking off the answer or filling in the blanks. All information is confidential. This form will only be seen by the Coordinator of Connections and will be kept in a secure file. By completing this form, you give your permission for Connections to use this information in summary form for Enhanced Placement evaluation purposes. “Summary form” means that your name and school/work affiliation will not be used on any evaluation documents; instead, the information will be used in statements about groups of students. Evaluation purposes include determining level of experience in behavioral health, previous degrees, etc.
Connections will not use the information you give for any purpose other than the evaluation of the EP program without your written permission.
We appreciate your providing this information.
Name:
Date you are filling this form out:
Degree program in which you are currently enrolled: ¨ BSW ¨ MSW ¨ LPC ¨ Ph.D. ¨ Psy.D ¨ Other:
Which seminar date you preferred: ¨ Monday ¨ Friday Your School: Your Mailing Address: City, State, Zip: Email: Home phone: Cell phone:Field Placement agency name:Field Placement agency department or program(s) you will be working in (if you know):
Agency field supervisor (name, title, dept/program, any contact info you have):
Name of the faculty member who is assigned to talk to you about your learning contract or other concerns or issues regarding your placement when necessary (advisor, head of practice class, etc.):
1. I have a bachelors degree in: ¨ Social Work ¨ Psychology ¨ Education ¨ Counseling ¨ Other (please describe) ____________________________________________ 2. I have a masters degree in: ¨ Psychology ¨ Education ¨ Counseling ¨ Other (please describe) ____________________________________________ 3. Before the degree program I am currently enrolled in, I worked in a behavioral health agency or setting (mental health, addictions, MR/developmental disabilities, other counseling—with children, adolescents and/or adults) ¨ Yes ¨ No 4. If you replied “yes” to #3 (above), approximately how many years had you worked in other behavioral health agencies or settings before starting your current degree program? ___________________
5. What types of behavioral health agencies did you work in, prior to your current degree program? ¨ Mental Health ¨ Addictions Treatment ¨ MR/Developmental Disabilities ¨ Other (please describe) 6. During the degree program I am currently enrolled in, I have worked in the following behavioral health agencies or settings (mental health, addictions, MR/developmental disabilities, other counseling—with children, adolescents and/or adults) ¨ Mental Health ¨ Addictions Treatment ¨ MR/Developmental Disabilities ¨ Other (please describe) 7. Approximately how many total years during your life have you worked in all types of behavioral health agencies (including during field placements, practicums, internships, etc.)? _____________ _______________________________________________________________________________
8.
In the following subjects/topics please check as many as
apply to indicate the amount of formal training you have had:
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