Master of Counselling – Placement Agreement

Name of Student:
Student ID:

PLACEMENT DETAILS
Placement Agency Name and Address:

Proposed Placement Start Date:

Proposed Placement End Date:
Proposed Hours/Days per Week:
Description of Placement Agency:
(general description including type of
clients, nature of problems seen, services
offered, staffing details)
Description of main tasks to be completed
on placement:
(type of counselling, administrative tasks,
meetings to attend, other expectations)

AGENCY APPROVAL FOR STUDENT TO UNDERTAKE THIS PLACEMENT IS PROVIDED BY: 󠇆

Agency 󠇆Representative’s 󠇆Full 󠇆Name:
Position at Agency:
Agency 󠇆Representative’s 󠇆Signature:

CLINICAL SUPERVISION FOR THIS PLACEMENT WILL BE PROVIDED BY THE AGENCY: 󠇆YES / NO󠇆 (Please circle)
Clinical 󠇆Supervisor’s 󠇆Full Name:
Clinical 󠇆Supervisor’s 󠇆Signature:

Before commencing my placement in the Agency in order to satisfy a compulsory part of the Master of Counselling
degree I acknowledge that I understand and fully accept the following:
1. Although the Agency may not be a part of the Faculty of Education, Monash University (“the Faculty”), I have been
accepted as a practicum placement student at the Faculty’s request, to allow me to gain experience in the normal
day-to-day operations of the Agency.
2. While undertaking my practicum placement I will be subject to the rules, regulations and by-laws of the Agency, and
will accept and comply with the Agency’s procedures and the directions of its staff.
3. Any unresolved complaint by the Agency about my actions or standard of conduct during my placement will be
referred as soon as practicable to the Faculty’s course coordinator. The Faculty will investigate the Agency’s
complaint under its applicable statutes and regulations (including the Discipline Statute) and may, if appropriate,
terminate my placement.
4. The Agency has a duty to ensure the safety and well-being of its clients, staff and members of the public on its
premises. If actions of mine prevent or impede the performance of that duty, and immediate notification of the
Faculty is impossible, the Agency may act at once to remove me from its premises, or refuse me admission (as the
case may be). The Agency will notify the Faculty of any such action as soon as practicable, and the Faculty will
investigate the matter as an alleged breach of discipline or act of misconduct under the Discipline Statute, or take
other such action as is appropriate under the statutes and regulations.

Student’s Signature: _______________________________________________ Date: _______________

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