Helen Bader School of Social Welfare - Field Program Resource Guide

Field Program Resource Guide Social Work Field Practicum Agencies

Social Work Field Practicum Agencies

COMMUNITY AGENCY INFORMATION FORM

Please take a few minutes to complete the following form. Your agency information will be included in the Helen Bader School of Social Welfare Field Program database and will also be included in our on-line Agency Resource Book, which is available for our social work students. If you are a large agency with multiple programs, please complete a separate form for each program that accepts social work students. (Our database is organized by individual programs within larger agencies due to the complexities of many of the agencies that we work with.)

If you have any questions regarding this form please contact the Director of Field Education: Jeanne Wagner: jeannew@uwm.edu or 414-229-6501.

* Indicates a required field
Date Submitted:		May 22 2013
Name of Agency/ Program or Department:	*
Name of Parent Organization (if applicable):
Agency Web Site Address:
Agency Type:	*
Agency Type Description:

Street Address:	*	(address line 1) (address line 2)
City:	*		State:	*	Zip:	*	-
County:	*	(select Wisconsin county or "not in Wisconsin")

Mailing Address:	*	(address line 1) (address line 2)
City:	*		State:	*	Zip:	*	-
County:	*	(select Wisconsin county or "not in Wisconsin")

Contact:	*	(first name) (last name)
Email:	*

Phone:

(area code)
(1234567 - omit dash)

Is your agency location on a primary public bus line?

Yes No

Are students required to use their own automobiles in the course of their duties?

Yes No

Do you accept BSW or MSW students?

BSW Students:

Yes No

MSW Students:

Yes No

Graduate students interested in becoming Licensed Clinical Social Workers must complete a minimum of two semesters of supervised clinical field training in a primary clinical setting (a facility, or a unit within a facility, whose primary purpose is to treat persons with a DSM diagnosis) where more than 50% of the practice is to assess and treat interpersonal and intrapsychic issues in direct contact with individuals, families or small groups (requirement of the State of WI Department of Regulation and Licensing).

Based on this description, would the field placement experience meet these requirements?

Yes No

Social Work Practice Areas
(check all that apply)

Behavioral / Physical Health Alcohol/Drug/Substance Abuse Behavioral Health/Community Mental Health Medical Social Work Administrative Social Work Other			Child Welfare Children and Youth School Social Work Administrative Social Work Other

Gerontology Aging/Gerontological Social Work Administrative Social Work Other			Other Criminal/Restorative Justice Community Outreach Developmental Disabilities Occupational/Industrial Social Work Physical Rehabilitation Services Public Assistance Programs Other

Agency Field Instructors
Please include all agency staff that are able to consider the placement of a social work student.
(At least one instructor is required.)

Instructor 1:
Name:	*	(first) (last)
Degree	*	BSW MSW Other (other)
Email:	*
Phone:	*	(area code) (number) (extension)
Fax:		(area code) (number)

Instructor 2:
Name:	(first) (last)
Degree	BSW MSW Other (other)
Email:
Phone:	(area code) (number) (extension)
Fax:	(area code) (number)

Instructor 3:
Name:
Degree	BSW MSW Other (other)
Email:
Phone Number:	(area code) (number) (extension)
Fax:	(area code) (number)

Instructor 4:
Name:
Degree	BSW MSW Other (other)
Email:
Phone Number:	(area code) (number) (extension)
Fax:	(area code) (number)

Instructor 5:
Name:
Degree	BSW MSW Other (other)
Email:
Phone Number:	(area code) (number) (extension)
Fax:	(area code) (number)

Instructor 6:
Name:
Degree	BSW MSW Other (other)
Email:
Phone Number:	(area code) (number) (extension)
Fax:	(area code) (number)