Spring 2019, Summer 2019, Fall 2019, and Spring 2020
Forms and Documents for COUN 239


This page requires Adobe Acrobat®, Apple Preview®, or some other .pdf document reader. Hours calculators are written in Microsoft Excel® (.xlsx). University-Agency Contract is in Microsoft Word® (.docx)
"Dot" key:   = items for Supervisors       = items for Trainees      = items for Everyone

Required on-line "mini-workshop" for Site Supervisors . . . 
   COUN 239: On-line "mini-workshop": Site Supervisors must complete our mini-workshop, entitled "Supervisor's Guide to COUN 239 - Field Placement in Counseling." This is a requirement of our CACREP accreditation. Please pay special attention to the instructions on the last page of the mini-workshop. This should take no more than 20 minutes.  (Updated: 02-10-2019) 
   COUN 239: On-line "mini-workshop" verification: Procedure to verify CACREP requirement of supervisor viewing COUN 239 tutorial.  

Course information for COUN 239 . . . 
   COUN 239: Course Syllabus sample (and model) for COUN 239 
   COUN 239: Handbook for COUN 239 - Field Placement in Counseling  

List of possible COUN 239 placement sites . . . 
   COUN 239: List of possible COUN 239 placement sites. This list is NOT exhaustive by any means; just because a site is on this list doesn't mean that it is taking trainees at this time. This list implies no guarantee of a placement. If you know of a site that should be on the list, please let Dan Smith know . . . and it will be included. 

Fresno State Interagency Risk Management Contract . . . 
   COUN 239: Five Year Contract between CSUF and your agency. The university and the agency will want to engage in a contract which specifies the legal relationship(s), sets the rules, and indemnifies each party from certain things. Attached is the INTERNSHIP AGREEMENT REQUIRED BY UNIVERSITY RISK MANAGEMENT, which is different from the Supervised Fieldwork Clinical Agreement Form that is found below. The Risk Management Agreement may already be signed and in place with your agency as it has a five-year contract life. If unsure, you can inquire with your agency if they have one; in needed, please have them fill in the blanks with their agency name address, etc., and sign it. You will return it to your instructor, who will forward it to Risk Management for their signatures and for filing. (This form will download in Microsoft Word .docx for completion.)  

COUN 239 Folder Assembly Forms and Instructions . . . 
   COUN 239: Starter-kit. A package of forms (from below) to copy and bring to the first day of supervision class. 
   COUN 239: Class Attendance/Activity Record. This form is to document your attendance and activities related to your COUN 239 class with your university supervisor. 
   COUN 239: Trainee Documents: Folder Assembly. A pictorial view of how the fieldwork trainee's documents folder is to be assembled and maintained. 
   COUN 239: Trainee Folder Paperwork Inventory. Inventory of items to be included in the COUN 239 folder, and date of entry. 
   COUN 239: Folder Assembly Completion Checklist. At the close of each semester, your university supervisor will utilize this form to make sure your folder conforms to required documentation standards. 

Forms pertaining to the placement setting and evauations . . . 
   COUN 239: Field Placement Information. 
   COUN 239: Site - Supervisor - Terms of Experience Form. "SST" - Formerly known as the "Fieldwork Contract." 
   COUN 239: Supervised Fieldwork Clinical Agreement Form. This is the "essential" four-way agreement that spells-out the relationship between the parties involved relevant to clinical supervision issues. (THIS IS NOT AN INTERAGENCY RISK MANAGEMENT CONTRACT) 
   COUN 239: Activity Log. Used for logging course hours: NOT FOR BBS HOURS  
   COUN 239: EXCEL CALCULATOR AND INSTRUCTIONS: Course Activity Log. Transfer your paper hours to this Excel form; it does the tabulations. 
   COUN 239: Student Professional Liability Insurance Program (SPLIP) - 2018-2019 Summary of Coverage. This is the insurance you purchase with your fees for COUN 239. 
   COUN 239: Student Professional Liability Insurance Program (SPLIP) - 2018-2019 Certificate of Liability Insurance. This is the insurance you purchase with your fees for COUN 239. You are not a "named insured" on this policy and it may or may meet the requirements of your agency. 
   COUN 239: Site Supervisor Evaluation. Trainee evaluation of site supervisor.
   COUN 239: Trainee Evaluation of Field Placement. Assessment of what the trainee thinks about the fieldwork site.
   COUN 239: Employer/Supervisor Evaluation of the CSU, Fresno Counselor Education Program. 
   COUN 239: University Supervisor Evaluation. Trainee evaluation of CSU, Fresno university supervisor.
   COUN 239: Final Evaluation of Counselor Trainee. Site supervisor's evaluation of trainee. 

Various live external links that are important to the class . . . 
   BBS Link: Responsibility Statement for Supervisors of a Marriage and Family Therapist Trainee or Associate. This form is absolutely required up-front, with no exceptions, if you plan to receive BBS hours.
   BBS Link: Responsibility Statement for Supervisors of an Associate Professional Clinical Counselor. This form is absolutely required up-front, with no exceptions, if you plan to receive BBS hours.
   BBS Link: Marriage and Family Therapist Trainee/Intern Weekly Summary of Hours of Experience - OPTION 1 ("Streamlined" Method). The weekly BBS hours log sheet. 
   BBS Link: Marriage and Family Therapist Trainee/Intern Weekly Summary of Hours of Experience - OPTION 2 ("Pre-Existing Multiple Category" Method). The weekly BBS hours log sheet. 
   BBS Link: Licensed Marriage and Family Therapist In-State Experience Verification - OPTION 1 (Summarizes the "Streamlined" Method). This is required for EVERY site; completed at the end of the experience. 
   BBS Link: Licensed Marriage and Family Therapist In-State Experience Verification - OPTION 2 (Summarizes the "Pre-Existing Multiple Category" Method). This is required for EVERY site; completed at the end of the experience. 
   BBS Link: Professional Clinical Counselor Intern Weekly Summary of Hours of Experience - OPTION 1 ("Streamlined" Method). The weekly BBS hours log sheet. 
   BBS Link: Professional Clinical Counselor Intern Weekly Summary of Hours of Experience - OPTION 2 ("Pre-Existing Multiple Category" Method). The weekly BBS hours log sheet. 
   BBS Link: Licensed Professional Clinical Counselor In-State Experience Verification - OPTION 1 (Summarizes the "Streamlined" Method). This is required for EVERY site; completed at the end of the experience. 
   BBS Link: Licensed Professional Clinical Counselor In-State Experience Verification - OPTION 2 (Summarizes the "Pre-Existing Multiple Category" Method). This is required for EVERY site; completed at the end of the experience. 
   BBS Link: Supervisory Plan for Professional Clinical Counselor Interns. Required of LPCC Interns. 
   BBS Link: Professional Therapy Never Includes Sex, 2011. This document must be with you in hard copy form when you practice . . . it's the law! 
   HDS Link: La Terapia Profesional Nunca Incluye Relaciones Sexuales, 2009 (for your Spanish speaking clients; newer version does not exist, but this one covers all the bases). This document must be with you in hard copy form when you practice . . . it's the law! 
   BBS Link: Associate Marriage and Family Therapist Registration Packet. 
   BBS Link: Associate Professional Clinical Counselor Registration Packet. 
   PC 11166 Link: Child Abuse Reporting Form and Instructions. Nice .pdf form to complete on your computer, or print and complete by hand. 
   WIC 15630 Link: Elder and Dependent Adult Abuse Reporting Form and Instructions. Nice .pdf form to complete on your computer, or print and complete by hand. 
   Grad Studies Link: "NEW" CSU, Fresno Petition for Advancement to Candidacy for the Master's Degree Find yours among the many . . . 

Updated: February 10, 2019 at 11:00 p.m.

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Questions regarding this page can be sent via e-mail to H. Dan Smith at dans@mail.fresnostate.edu