Checklist of Forms/Assignments

EDCO 389 Counseling Internship Checklist of Forms/Assignments

The list below includes all of the forms and assignments for the Internship experience. All of the items on this list are due in a packet submitted to the instructor at the end of each semester (unless otherwise indicated below). See Instructions for Checklist of Forms/Assignments for more information about these forms and submission requirements.

Date Submitted	Student Name
	Description
	Form #1 - Internship Application (Only required prior to first semester. Indicate date submitted. Application does not need to be included in end of semester packet.) PDF
	Form #2 – Internship Placement Contract (Due prior to semester/start at placement. Staff must have a current Contract for each semester student is at placement. Please see CP staff to see if this form needs to be re-submitted during current semester. Indicate date discussed with staff. Include copy of Contract in packet at the end of the semester.) PDF or MS Word
	Intern Behavior Contract (Signed and submitted by the student prior to the start of the a new academic year or new site.) PDF
	Supervisor Contract (Signed by the site-supervisor and submitted to the faculty supervisor/staff at the start of the semester.) PDF
	Proof of Insurance (This must be submitted by student prior to working on site. Insurance must be valid for all of the semesters that student is working on site.)
	Form # 3 -Internship Competency Checklist (Note: there are separate forms for MH and SC Internships. The Competency Checklist should be completed by site supervisor.) SC PDF or SC Word; MH PDF
	Form #4 - Student Evaluation of Internship Site (Completed by student.) PDF or MS Word
	Form #5 - Student Evaluation of Site-Supervisor (Completed by student.) PDF or MS Word
	Form #6 - Site-Supervisor’s Evaluation of the UVM Counseling Program (Completed by site-supervisor.) PDF or MS Word
	Internship Accountability Form (Completed by student. Original form [available from staff] must be used. All hours must match final Log of Hours. All signatures must be on form at time of submission. Student should retain copy of this form.) PDF or MS Word
	Hour Logs (Hour logs for semester must be submitted at the end of the semester. Student should keep copies.) Excel
	Case Presentation (Does not need to be submitted in packet. Indicate date completed in class.)
	Referral Log (Submit to instructor –does not need to be included in packet. Indicate date submitted.)
	Reading List (Submit to instructor –does not need to be included in packet. Indicate date submitted.)
	Dates of Site Visit(s) (Indicate: Site Visit/Phone Contact)
	#1
	#2
	#3

Instructions for Internship Forms

Each Internship student is responsible for submitting the Checklist of Forms as the cover-page for the packet of forms submitted to the faculty supervisor/instructor at the end of each semester of Internship. Students must indicate the date of completion/submission of each requirement on the checklist. Grades will not be issued and recommendation for licensure will not be processed without the Checklist of Forms completed and accompanying all original forms. All are required to be submitted by the due date given by the instructor.

When submitting final Internship paperwork, all work should be included in a packet as indicated below:

Checklist of Forms

The Checklist must be submitted as the cover page of the packet of forms that is submitted to the faculty supervisor/instructor at the end of the semester on the due date indicated in the course syllabus. Each form on the list must be dated/checked as indicated as completed and all required forms must be attached (in order) to the checklist at the time of submission.

Form 1

The Application is submitted by the student to CP staff one semester prior to registering for Internship. This does not need to be submitted with end-of-semester packet/checklist. The student is responsible for meeting with his/her advisor prior to completing this form.

Form 2

CP staff needs an Internship Placement Contract that is valid for each semester of Internship. The student is responsible for checking with staff each semester to be sure that his/her Contract is valid. A copy of the valid contract should be submitted with end-of-semester packet/checklist.

Intern Behavior Contract Signed and submitted by the student prior to the start of the new academic year or at a new site.

Proof of Insurance

CP staff needs a copy of the student’s liability insurance. This must be submitted prior to the start of the first semester of Internship and it must be valid for each semester of Internship. Students must document on the checklist the date that they checked with CP staff each semester to assure that the copy of the policy is on file and is currently valid.

Form 3

The Mental Health Internship Competency Checklist is completed by the site-supervisor each semester for Mental Health Track counseling students. (There is a separate competency checklist for the Mental Health and School Counseling internships.) Goals are established at the end of the semesters 1 and 2 and reviewed at the end of semesters 2 and 3, with comments from the site-supervisor. It is the student’s responsibility to see to it that the site-supervisor has completed and signed this form by the due date at the end of the semester. The student must also sign it, and the faculty supervisor will complete the bottom portion indicating whether the student has completed all the requirements to pass the semester. Again, the goal-setting portion of this form does not need to be completed the first semester –except that goals are identified at the end of the first semester and added to the checklist for the following second (and third) semester.
The School Counseling Internship Competency Checklist is completed by the site-supervisor each semester for School Counseling Track counseling students. (There is a separate competency checklist for the Mental Health and School Counseling internships.) Goals are established with the site-supervisor at the end of the first semester and at the start of the second semester and reviewed at the end of the second semesters. It is the student’s responsibility to see to it that the site-supervisor has completed and signed this form by the due date at the end of the semester. The student must also sign it, and the faculty supervisor will complete the bottom portion indicating whether the student has completed all the requirements to pass the semester. Again, the goal-setting portion of this form does not need to be completed the first semester –except that goals are identified at the end of the first semester and added to the checklist for the following second (and third) semester.

Form 4

The Student Evaluation of the Internship Site is completed by the student each semester. It must be included in the end-of-semester packet/checklist. Students should be discussing the content of this form with their site-supervisor at the end of the semester.

Form 5

The Student Evaluation of the Site-Supervisor is completed by the student each semester. It must be included in the end-of-semester packet/checklist. Students should be discussing the content of this form with their site-supervisor at the end of the semester.

Form 6

The Site-Supervisor’s Evaluation of the UVM Counseling Program is completed by the site-supervisor each semester. It must be included in the end-of-semester packet/checklist. Site supervisors who have a student for multiple semesters are invited to edit a previously submitted version of this form if this is easier for them.

Accountability Form

The Accountability Form is the official documentation of student hours that is kept in the student file and used in the future for internship verification. It is essential that: (1) the original form be used each semester. This form will be held in the student’s file and the student must request it from the CP staff for end-of-semester reporting of hours and signatures, (2) the hours documented on this form must be consistent with the hours reported on the Log of Hours, (3) all signatures must be on the form, (4) hours should be reported in whole or half hours only (quarter of hours should be rounded up or down), (5) all students should make a copy of this form for their own records prior to submitting it at the end of the semester.

Hours Log

All of the Hour Logs for the semester must be submitted in the packet at the end of the semester. Each hour log must have site- and faculty-supervisors initials and the numbers reported on the logs must be consistent with those reported on the Accountability form.

EDCO 389 Counseling Internship Checklist of Forms/Assignments

Date Submitted

Student Name