NMHU SCHOOL OF SOCIAL WORK



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SCHOOL OF SOCIAL WORK - AGENCY FIELD PRACTICUM APPLICATION

SCHOOL OF SOCIAL WORK MISSION STATEMENT

The Mission of the School of Social Work is to educate students to practice social work competently with the diverse, multicultural populations of New Mexico and the Southwest. The School has a primary commitment to Hispanic and Native American people. Our curriculum grounds students in core professional social work values, skills and ethical principles, with a focus on promoting awareness and respect for cultural and gender differences and how poverty affects the well being of people in the region.

AGENCY DEMOGRAPHIC SECTION

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|_______________________________________________________ ______________________________________ |

|Agency Name-Division/Department (if applicable) Director/Program Administrator |

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|_______________________________________________________________________________________________ |

|Mailing Address City State Zip |

| |

|__________________________________ _________________________ ____________________________ |

|Agency Phone Number Fax Number E-mail Address |

| |

|__________________________________ |

|Website Address (if applicable) |

Type of Agency.

[ ] Governmental (federal, state, county, city)

[ ] Private non-profit

[ ] Private for profit

[ ] Other, specify _______________________

1. What type of client fee schedule does your agency use? Check all that apply.

[ ] No fees

[ ] Sliding fee scale

[ ] Set fees

[ ] Third party payments

[ ] Other, specify ____________________

2. What percentage of your agency budget is from the following sources?

Medicaid __________ %

Medicare __________ %

Client Fees __________ %

Indian Health Service __________ %

Contract (State, Federal) __________ %

Other, specify_________________ __________ %

3. Provide a demographic profile of your current agency personnel.

| | |

|NUMBER OF STAFF BY DISCIPLINE |OTHER DISCIPLINES |

| |

| | Male | Female |

|African American | | |

|Asian American | | |

|Hispanic | | |

|Native American | | |

|White/ Caucasian | | |

|Other | | |

|Total | | |

6. Do the client/consumer demographics reflect the population that field practicum students will be working with?

________ Yes _______ No (If no, please explain)

____________________________________________________________________________________________

____________________________________________________________________________________________

7. What client/consumer age groups are served by your agency? (Check all that apply)

[ ] Children 0 – 3 years

[ ] Children 4 – 5 years

[ ] Children 6 – 10 years

[ ] Children 11 – 13 years

[ ] Adolescents 14 – 17 years

[ ] Adults 18 – 35 years

[ ] Adults 36 – 65 years

[ ] Adults 66 years & older

8. Which of the following best describe the services your agency provides? (Check all that apply)

[ ] Intakes/Assessments

[ ] Case Management

[ ] Administration/Program Planning

[ ] Research/Program Evaluation

[ ] Therapy/Counseling

[ ] Community Organization (advocacy, networking, lobbying, etc).

[ ] Educational/Oral Presentations

[ ] Other: (please specify) __________________________

1. Why is your agency interested in becoming a practicum site?

2. How many years has your agency been in operation?

3. How many program locations does your agency have and in which communities?

4. Describe how your agency will provide learning opportunities that will enhance and promote the Schools’

Mission and the learning expectations of our students.

5. Please indicate how the practicum will be structured and designed at your agency and the kinds of activities and projects the students will be assigned.

6. How is your agency/site promoting or addressing cultural awareness/competence and incorporating the

following Cultural Competency Standards? Please elaborate.

a. Socio-Cultural Factors in Health Care Delivery

b. Population Health Disparities

c. Intercultural communication

d. New Mexico Historical Trauma (if agency is NM based)

7. How many students (by classification) is your agency capable of accepting for practicum placement?

______ BSW

______ MSW 1st year

______ MSW 2nd year - Indicate below how many 2nd year students your agency can accept within each of the concentrations.

_____ Clinical Practice _____ Government Non Profit _____ Bilingual/Bicultural Clinical Practice

Management

8. Does your agency have a particular theoretical practice orientation (i.e., Behavioral, Psychodynamic)?

9. Is your agency’s Board of Directors/ Chief Administrative Office committed to the agency functioning as a field practicum site for social work students and allowing agency instructors time to carry out the supervising responsibilities as set forth by the School of Social Work? _______ Yes ______ No

10. Will student be expected to travel? ________ Yes ______ No

11. If yes, will agency reimburse the student for travel? _______ Yes ______ No

(The School of Social Work prohibits students from transporting clients. Refer to field manual for details.)

12. Will your agency be able to provide the student with workspace, materials, supplies and phone access

needed to complete practicum responsibilities? _______Yes _______ No

13. Do you have any special requirements of student (i.e., language proficiency, drivers license, special hours, attendance at specific meetings/ trainings, continuing client visits during school breaks)? Please describe.

14. Can the agency provide financial support for the student(s) practicum? ______ Yes _______ No

15. If yes, please indicate the type and amount of financial support your agency can provide.

__________________________________________________________________________________________

16. Will the student have the opportunity to directly observe the agency instructor carrying out his/her

professional role (i.e., observing agency instructor working with clients)? ______ Yes _______ No

If no, please explain.

17. If your agency does not have MSW personnel to supervise, can arrangements be made to have MSW

supervision? ______ Yes _______ No

_________________________________________ ______________________________ __________________

Print Name and title of person completing form Signature Date

Depending on the location, of your agency submit Agency Application, Memorandum of Agreement, and

Agency Instructor Application to relevant program location:

NMHU-School of Social Work (Attention: Field Director),

Box 9000 Las Vegas, NM 87701

(505) 454-3326/ 454-3294. FAX: (505) 454-3290

NMHU School of Social Work @ Albuquerque (Attention: Field Coordinator),

5041 Indian School Rd NE Suite 100, Albuquerque, NM 87110

(505) 260-6190/260-6182 FAX: (505) 896-6122

NMHU School of Social Work In Partnership with San Juan College (Attention: Field Coordinator),

3539 E. 30th Street #203 Farmington, NM 87402

(505) 566-3552, FAX: (505) 566-3584

NMHU School of Social Work In Partnership with ENMU-R (Attention: Field Coordinator),

P. O. Box 6000, Roswell, NM 88202

(575) 624-7458, FAX: (575) 624-7457

Enclose pamphlets, brochures, and literature that describe your agency and services

Online Document Link 1129 Rev 11/1/12

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FIELD AGENCY REQUIREMENTS & PRACTICUM OPPORTUNITIES

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