THE SOCIAL WORK PROGRAM

Three Agencies Form

INTRODUCTION TO STUDENT’S RESPONSIBILITIES: READ CAREFULLY!

Hello Senior Interns. Please note the following instructions regarding gathering information for
your Three Agencies Form.
Student responsibilities:

 Obtain the information requested on the form.

 Inform the agency that a field faculty member will contact them to provide additional
information and detail
 Submit the completed form online as soon as possible

Field Faculty Responsibilities:

 Vet the agency for appropriateness and scope of work interns engage in
 Secure the placement on your behalf
 Provide detailed information about practicum and the Department's requirements
 Secure required documentation
 Refer you to the appropriate person for interview
 Obtain interview feedback from the agency

What you are NOT responsible for:

 Securing a placement
 Securing an interview prior to Faculty referring you for interview.
 Getting the agency to accept you as an intern
 Asking information about the agency that is not required on the form, or that you need to
decide if you would like the agency considered.

What happens once you submit the form:

All vetting, information about the program, completing the paperwork, gaining agency agreement
to take on an intern, answering questions about requirements, supervision or other practicum
issues - will be completed by the Field Faculty assigned to help you gain a placement. Field Faculty
contact all agencies listed on the form and complete this process to secure an agency possibility for
each student.
Agencies contract with the University - NOT students, so engaging in faculty responsibilities by any
student in not appropriate. Students are given a cheat sheet, so that they can reasonable answer
initial questions, but students’ responses should always include, "a Field Faculty member will
contact you with details about the program shortly."
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If you have any questions about how to proceed, please feel free to contact Director Sibyl Beaulieu
or Assistant Director Justine Rangel. Otherwise, please review the following
instructions/information and complete the Three Agencies Form. Once completed, please submit
to your application. If you are interested in the agency, we will investigate it to see if we can utilize
the agency as a placement for you. We will do the heavy lifting on your behalf. For additional
questions or concerns please contact Prof. Sibyl or Prof. Justine.
sbeaulie@brandman.edu or jrangel@brandman.edu

Please review and complete the attached form. (See below)

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INSTRUCTIONS ON COMPLETING THE FORM: PLEASE READ THE FOLLOWING CAREFULLY:

Please provide information for three agencies in your community where you could do your Field
Experience practicum. You must contact these agencies to ensure they will take a BSW level
student and that they have a social worker with an MSW or BSW (from a CSWE accredited school)
who could provide you weekly supervision. If they do not, please find out if they currently
supervise social work students (not having a BSW or MSW supervisor may not prevent agency
approval). The Field Director or Asst. Director, will provide the internship packet and answer any
questions with any agency that is open to considering an intern, as well as explain the student and
agency responsibilities required. Please note: Forms submitted with agencies that have not
been contacted and without ALL information requested will not be processed, which will
delay your placement. Only TYPED and fully completed forms will be accepted. PLEASE MAKE
SURE TO INCLUDE THE HIGH-LIGHTED AREAS

ENSURE TO PUT YOUR NAME ON THIS FORM

STUDENT NAME:
First Agency Name:
Type of Service Provided (aging, child welfare, medical, etc):
Agency Location (city/state/country):
(Highlight the correct answer)
Does this agency take BSW level students? Y N
Does this agency have an MSW or BSW to provide supervision? Y N
Does the agency currently have social work interns? Y N
Name of contact you verified this above information with: Title:

(This is NOT their name, but

Agency title (e.g. Director, etc…)
Are they the contact for internships or someone else? Y N
If not, identify the contact: Title:
Number: E-mail:

Second Agency Name:

Type of Service Provided (aging, child welfare, medical, etc):
Agency Location (city/state):
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(Highlight the correct answer)
Does this agency take BSW level students? Y N
Does this agency have an MSW or BSW to provide supervision? Y N

Does the agency currently have social work interns? Y N

Name of contact you verified this above information with: Title:
Are they the contact for internships or someone else? Y N
If not, identify the contact: Title:
Number: E-Mail:

Third Agency Name:

Type of Service Provided (aging, child welfare, medical, etc):
Agency Location (city/state):
(Highlight the correct answer)
Does this agency take BSW level students? Y N
Does this agency have an MSW or BSW to provide supervision? Y N
Does the agency currently have social work interns? Y N
Name of contact you verified this above information with: Title:
Are they the contact for internships or someone else? Y N
If not, identify the contact: Title:
Number: E-Mail:

SUBMIT THIS FORM AS AN ATTACHMENT WITH YOUR APPLICATION. IF YOU HAVE DIFFICULTY,
PLEASE FORWARD TO GRETCHEN HARPER.
ANY FORM SUBMITTED WITH INCOMPLETE INFORMATION WILL NOT BE UTILIZED, NOR WILL
ANY EFFORTS TO SECURE YOUR PLACEMENT OCCUR, UNTIL THE FORM IS COMPLETE.