Field Education - Wellstar College of Health and Human Services

Please complete the forms below if your agency is interested in accepting MSW student interns from Kennesaw State University. Once reviewed, your agency will be contacted and if appropriate, schedule an orientation. While we understand that some of the placements are without compensation, please consider developing stipends to assist our students.

Please review the KSU MSW Handbook for agency and field supervisors’ expectations and approval to determine appropriateness of your agency for MSW placements.

Agency Interest Form

If you see this don't fill out this input box.

Name of Agency

Street Address

City

State

Zip

Phone Number

Email

Primary contact(s) for internship placements

Are there stipends available for students?
YesNo

If so, how much?

Select FOUNDATION Internships
MSW Foundation Internship (First-Year MSW Students)

Requires supervision by an MSW or LMSW, LCSW preferred

Two eight-hour days/week (Monday and Tuesday) — Indicate Agency Focus:
Children & FamiliesMental Health(Substance Abuse)All

Select ADVANCED Internships
MSW Advanced Internships (Second-Year MSW Students)

Requires supervision by an LCSW

Three eight-hour days/week (Wednesday, Thursday, Friday) — Indicate Agency Focus:
Children & FamiliesMental Health(Substance Abuse)All

Supervision will be provided by
MSWLCSWLMSWLPC w/LMSW Back Up for 1-Hour Weekly Supervision

Identify the POPULATION(S) that is/are served at this agency:

Identify the RESPONSIBILITIES the interns may have at this agency:

*If approved, the agency and field supervisors agree to follow the guidelines and responsibilities established in the Master of Social Work program at KSU

by entering your name you are signing this form
Field Supervisor Interest Form

If you see this don't fill out this input box.

Agency Contact Person

*First Name

*Last Name

*Title

*Phone

*Email

*Do you have a MSW?
YesNo

*Do you have two years post-MSW degree experience?
YesNo

*Please indicate your highest degree

*Would the agency contact person also be serving as a field supervisor?
YesNo

*Will the field supervisor be able to commit to 1 hour per week per student for direct supervision?
YesNo

Field Supervisor

Please list the person who may be the field supervisor if different than agency contact person. Please list all those in the agency who are interested in supporting students for a placement opportunity for the academic year and the maximum number of students for EACH supervisor.

Please Note: Field supervisors for all MSW students must have two years post-degree experience. Field supervisors for first-year MSW students must have a MSW and/or LMSW--an LCSW is preferred. Field supervisors for second-year MSW students must have a valid LCSW licensure to practice independently in the State of Georgia. An LPC can provide supervision for daily tasks; however, an LCSW is required to provide one hour of weekly supervision.

Please send a resume and license for new field supervisors.

*First Name

*Last Name

*Title/License

*Phone

*Email

*Do you have a MSW?
YesNo

*Do you have two years post-MSW degree experience?
YesNo

*Please indicate your highest degree

*Do you have a valid license to practice in the State of Georgia?
YesNo

*If so, please indicate your license
LMSWLMSW-AGLCSWLPCLSWOther

Agency Information

*Street Address

*City

*State/Province/Region

*Postal/Zip Code

*Phone

Website

*Choose an area, or areas, of interest that best describe the placement opportunity
Children/FamiliesMental HealthSubstance AbuseOther

*Describe the Mission of the Agency/Organization

*Describe the Work/Services of the Agency/Organization

*Describe the composition of the professional staff

*Describe the Social Work Student Tasks/Assignments/Responsibilities

*Describe any additional education opportunities for the student

*What are the agency hours for field placement?
MorningsAfternoonsEveningsWeekends

*Are there opportunities for more than one student?
YesNo

*Please indicate the number of MSW Foundation (1st year) students that can be supervised at your agency and work in a field placement for 16 hours a week. These students are in their first field placement. (Mondays & Tuesdays)

*Please indicate the number of MSW Specialization (2nd year) students that can be supervised at your agency and work in a field placement for 24 hours a week. MSW Concentration year students are in their final field experience. (Wednesday, Thursday & Fridays)

MSW Field Questions

*Our agency is able to accept KSU students now
YesNo

*Tentatively we cannot take KSU students now, but please contact me again next year
YesNo

*Does your agency require a background check?
YesNo

*Does your agency require a TB test or immunizations? (i.e. Tetanus)
YesNo

*Does your agency require a drug screen?
YesNo

*Does your agency require a medical screen?
YesNo

*Does your agency pay for the cost of required items?
YesNo

*Does your agency require the student to have reliable transportation?
YesNo

*Does your agency offer mileage reimbursement to the students?
YesNo

*Does your agency require a writing sample?
YesNo

*Does your agency require AIDs training?
YesNo

*Does your agency require CPR training?
YesNo

*Does your agency require proof of auto liability insurance?
YesNo

*Does your agency require orientation?
YesNo

*Are there opportunities for students to have a paid field placement? (e.g. agency stipend, part-time employee status, grant)
YesNo

*Does your agency have any additional requirements?

*Are you a KSU alumni or how did you learn about our program?

Please send Field Supervisor resume and license to

KSU Field Education Coordinator
Master of Social Work Program
Kennesaw State University
520 Parliament Garden Way
Kennesaw, GA 30144

Fax: 770-794-7559
Email: kennesawmswfieldeducation@kennesaw.edu

If you have any questions, please call 470-578-7560
Forms

VICTORIA A. CORRIGAN, MSSA, LSW, LMSW
Director of Field Education for the Master of Social Work Program
Department of Social Work and Human Services

Wellstar College of Health and Human Services
520 Parliament Garden Way NW
Room 3209, MD 4103
Kennesaw, GA 30144

Phone: 470-578-7562

Student Internships