Practicum Partnership Interest Form

Please complete the Practicum Partnership Interest Form below to be considered for our practicum program. Upon receipt of your submission, Simmons School of Social Work faculty will follow up with you with a verbal conversation and further screening questions.

Agency Name
Program Name

Please be as specific as possible. If you are part of a large organization, please include identifying information such as the program, department, or town/city of the program
Agency Address Agency Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
If you are located more than 2 hours from Boston, please complete this form to get in touch with the SW@S Online MSW Practicum Education Department: SocialWork@Simmons Practicum Education - Qualification Form
Agency Website
Agency Phone Number Agency Phone Number - ### - ### ####
Agency Fax Number Agency Fax Number - ### - ### ####
Authorized Site Representative

This is your agency's lead contact for internships. This person is responsible for establishing the partnership with Simmons School of Social Work and ensuring that Simmons has the latest information on file, including internship descriptions, application instructions, and contact information.
Representative Name Representative Name First Last
Representative Title
Representative Phone Representative Phone - ### - ### ####
Representative Email
Social Work Director

If this is the same person as main contact above, you may leave the Social Work Director fields blank.
Social Work Director Name Social Work Director Name First Last
If this is the same person as main contact above, you may leave the Social Work Director fields blank.
Social Work Director Title
Social Work Director Phone Social Work Director Phone - ### - ### ####
Social Work Director Email
Training Director

If this is the same person as main contact above, you may leave the Training Director fields blank.
Training Director Name Training Director Name First Last
If this is the same person as main contact above, you may leave the Training Director fields blank.
Training Director Title
Training Director Phone Training Director Phone - ### - ### ####
Training Director Email
Credentials

What are the credentials of your agency’s supervisors?
Select all that credentials that apply:

Select all that credentials that apply: LCSW LICSW LMHC SAC Other Other
Are you reaching out for any of the following reasons? Please select all that apply

Are you reaching out for any of the following reasons? Please select all that apply A Simmons student reached out to my agency for placement We are interested in hosting a specific Simmons student We are interested in hosting any suitable Simmons student
We are interested in hosting a specific Simmons student (additional information required)
Simmons Student Name Simmons Student Name First Last
Who initiated this opportunity?

Who initiated this opportunity? The student contacted the agency The agency contacted the student
Are you seeking interns for any of the following periods? Please select all that apply

Are you seeking interns for any of the following periods? Please select all that apply Start in the upcoming academic year (Sept-May) Start outside of the regular academic year (mid-year, over the summer, etc) Start immediately
Please share any additional comments or information about your agency that you would like Simmons to know.
PLEASE NOTE:

Practicum Instructors who have not already taken a Supervision Seminar are required to do so. This requirement can be met by taking the seminar offered annually by Simmons or by any other school of social work.

Practicum Partnership Interest Form

Practicum Partnership Interest Form

Authorized Site Representative

Social Work Director

Training Director

Credentials

We are interested in hosting a specific Simmons student (additional information required)

PLEASE NOTE: