St. Scholastica Social Work
Field Placement Agency Questionnaire

Dear Valued Field Placement Agency:
We appreciate your time and dedication to be a part of our field program. This agency questionnaire will provide information about your agency to be matched with student's interests in the Social Work Field Program. Please complete all questions to the best of your ability. If you should have any questions please contact your local CSS Field Faculty.

*Required

Agency Information
*Agency:
*Agency Auspice:
*Agency Address:
*City:
*State:
*Zip:
*County:
   
Website:


*Contact Person:
  
*Title:
*Email Address:
  
*Phone #:


Your Information


*Please check 'Same as Above' if you are the Contact Person listed above, or fill out the fields below.

Same as Above

OR

Person Completing Form (You): 
Title:
Phone #:
Email:

Please list your professional academic degree(s), licensure and/or certification:


Service Details
This information will allow students to search our database for agencies they are interested in based on the following categories and details.

*Top categories which best describe your primary agency service (check all that apply):

 Administration
Aging/Gerontological
Alcohol/Drug/Stubstance Abuse
Child Welfare
Community Planing
Corrections/Criminal Justice
Developmental Disabilities
Domestic Violence or Crisis Intervention
Family Services
Group Services
Health
Housing
International
Mental Health or Community Mental Health
Program Evaluation
Public Assistance/Public Welfare
Rehabilitation
School Social Work
Social Policy


*Primary Target Populations (check all that apply):

 Individuals
Preschool
Caucasian
Families
Children
Native American
Groups
Adolescent
African American
Communities
Adult
Asian
Organizations
Elder
Hispanic
Refugee/Immigrants
Gay/Lesbian/Bisexual    


*Intern Activities (check all that apply):

 Client Assessments/Intakes
Case Management
Individual Counseling
Group Counseling
Client Follow-up
Public Policy Activities
Court Hearings
Social/Community Activism
Community Development
Agency Research
Client Treatment Planning
Client Outcome Evaluation
Documentation
Advisory Bds, Tasks Group, Planning Mtg
Crisis Intervention
Emergency Assistance (i.e. food shelf, housing)
Family Counseling
Financial Assistance
Community Referrals
Client Socialization Activities
Refugee Settlement
Adoption
Education (i.e. parenting, health)
Program Evaluation/Quality Assurance
Client Discharge Planning
Team Meetings, Staffings, Care Conferences
Program Development    


*Days and Times placement opportunities are available (check all that apply):

Monday Morning Afternoon Evening
Tuesday Morning Afternoon Evening
Wednesday Morning Afternoon Evening
Thursday Morning Afternoon Evening
Friday Morning Afternoon Evening
Saturday Morning Afternoon Evening
Sunday Morning Afternoon Evening




Opportunity Information

Consider what opportunities you may be able to offer our social work students, then respond to the following questions:

Please type or paste a description of your agency and what you do (mission statement, vision, values, goals, etc.). This description will be read by students.


Please type or paste the description of the intern position(s) your agency offers. This description will be read by students.


*In reviewing the three levels of student internship opportunities our program offers, please check which level(s) of learning you believe your agency or department can accommodate. Please check all that apply:
Sophomore Level Junior Level Senior Level




Other Comments For Students:


Agreement

*You must read the following agreement and check the box in order to continue.

As a representative of my agency, I agree to provide an internship opportunity for The College of St. Scholastica's Field Education Program. As a representative of my agency, I give the CSS Field Education Program permission to share any information about my agency in order to arrange a field placement within my agency.