Practicum Instructor Profile Form

Practicum Instructors/supervisors should be fully qualified according to Simmons SSW standards. Read more about the Expectations for Practicum Instructors.

Name Name First Last
Agency
Agency Address Agency Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Fax Fax - ### - ### ####
Email
Highest Level of Education/Degree Completed
License Type (select one)

License Type (select one) LCSW LICSW LMHC Other I do not have a license
Other License Type
License #
Expiration Date Expiration Date / MM / DD YYYY
School Adjustment Counselor License # (if applicable)
Type of License

Type of License Initial Professional
Certifications
Do you have previous experience as a primary MSW student supervisor?

Do you have previous experience as a primary MSW student supervisor? Yes No
Have you previously attended a seminar/course on MSW supervision (ex. Seminar in Practicum/Field Instruction (SIPI/SIFI))?

Have you previously attended a seminar/course on MSW supervision (ex. Seminar in Practicum/Field Instruction (SIPI/SIFI))? Yes No
To meet re-accreditation standards, we are required to have a resume on file for every instructor who supervises an MSW student.

Resumes must include:
• Education (Master's or higher at least)
• License type and number
• Certifications
• Current agency, position title, and at least 3 bullets summarizing the job responsibilities

Attach Files

When adding your resume, please make sure the only dot/period in the filename is prior to the file type/extension (example - resume.pdf or resume.docx).

Having a dot/period in the file name itself may cause an error when uploading.
If you answered "no" to the previous two questions, please visit our webpage for more information about our Seminar in Practicum Instruction at Simmons University.
What is your approach to supervising students? If you have not yet supervised a student, please share other supervisory experiences or plans for future supervision.
Expectations for Practicum Instructors

Expectations for Practicum Instructors Check this box to affirm that you have read the University’s Expectations for Practicum Instructors