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 the UWRF Social Work Field Placement coordinator.

*Required

Agency Information

*Agency: 

*Agency Auspice:

*Agency Address: 

*City:   *State:

Zip: 

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:

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/Substance Abuse

Child Welfare

Community Planning

Corrections/Criminal Justice

Crisis Intervention

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

Families

Groups

Communities

Organizations

Refugee/Immigrants

Preschool

Children

Adolescent

Adult

Elder

Caucasian

Native American

African American

Hispanic

Asian

Gay/Lesbian/Bisexual

Veterans

Intern Activities (check all that apply):

Client Assessments/Intakes

Case Management

Individual Counseling

Family Counseling

Group Counseling

Community Referrals

Court Hearings

Social/Community Activism

Community Development

Agency Research

Client Treatment Planning

Client Outcome Evaluation

Documentation

Advisory Boards, Tasks Group, Planning Mtg

Crisis Intervention

Emergency Assistance (i.e. food shelf, housing)

Financial Assistance

Public Policy Activities

Client Socialization Activities

Client Follow-up

Refugee Settlement

Adoption

Education (i.e. parenting, health)

Program Evaluation/Quality Assurance

Client Discharge Planning

Program Development

Team Meetings, Staffings, Care Conferences

Work Hours

Our students are expected to be in their field placements Monday, Wednesdays and Fridays from 9 am to 5 pm.

Do these hours match your agency needs?

Yes

No

If you selected no, what days/hours do you need an intern for?

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.

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 University of Wisconsin-River Falls Social Work Field Education Program. As a representative of my agency, I give the UWRF Social Work Field Education Program permission to share any information about my agency in order to arrange a field placement within my agency.