MU.

A11
DATE ISSUED: 8/89
DATE REVISED: 5/16
Mansfield University of Pennsylvania
Mansfield, PA 16933
INTERNSHIP FORM
Bookard Alexis B 0467512
LAST NAME FIRST MI Student ID

2427 Fleetwing Dr. 267 597 0862

HOME ADDRESS PHONE

Levittown Pa 19057
CITY STATE ZIP

50 Morris Dr #882
ADDRESS DURING INTERNSHIP PHONE

Mansfield PA 16933
_________________________________________________
CITY STATE ZIP

122 05/14/2022 Psychology

CREDITS EARNED GRADUATION DATE MAJOR

SP 1/24/20 05/12/2022
SEMESTER START DATE END DATE

PSY 4495 6
PREFIX COURSE # CREDIT HOURS

NAME OF FACULTY SUPERVISOR PHONE

Regan Parshall-Youth Clubhouse Supervisor TC Commons Clubhouse

NAME & TITLE OF ON-SITE SUPERVISOR AGENCY NAME

650 Baldwin Street rparshall@casa-trinity.org

AGENCY ADDRESS SITE SUPERVISOR EMAIL

Elmira NY 14901 607-737-5212 ext.3205

_____________________
CITY STATE ZIP PHONE

ALEXIS BOOKARD 12/08/21

STUDENT SIGNATURE * DATE

MAXIMUM TRAVEL COSTS TO BE INCURRED IN SUPERVISING INTERN

FACULTY SUPERVISOR DATE DEPARTMENT CHAIRPERSON DATE

Approved Internship Agreement
on file
State Authorization on file
DEAN/PROVOST DATE
* Student signature authorizes faculty supervisor to discuss student with on-site
supervisor.
Return To: Registrar’s Office, 224 South Hall for Dean/Provost review
MU.A11
DATE ISSUED: 8/89
DATE REVISED: 5/16

Last Name First MI Student Id

Total credits earned GPA

Total internship hours Credits requested

Please submit a detailed learning outcome and assessment plan. For requests received after
payment due date submit payment with application.

Specify the learning outcomes for this internship:

(Per the guidelines for the undergraduate internship developed by the faculty of the Psychology Department): Develop and
apply basic psychology based knowledge and skills in an applied community setting, including: 1. Learning agency
procedures and expectations for staff conduct, 2. Developing skills in direct contact and basic counseling with agency
clients, 3. Performing basic applied tasks of line staff (including learning to implement staff writing tasks, such as progress
notes on clients), 4. Developing five (minimum) learning objectives with agency supervisor within first 10 working days of
internship (to be approved by M.U. faculty internship supervisor).

Specify the functions the student will complete during the internship:
Engage in applied tasks to meet the above general and specifically developed objectives; participate in other activities with
staff of the agency (e.g., treatment team discussions, staff development, writing notes and reports, actively participating in
supervision).

Specify the academic tasks the student will complete related to this internship:
Keep weekly progress notes on accomplishment of the above tasks; mail periodic written reports (every two weeks) to the
M.U. faculty supervisor; write a comprehensive mid-term and final summary report of the internship experience to be
shared with both on-site and M.U. supervisors; complete the Internship Summary Form as a permanent summary record of
the internship experience.

Specify the criteria used to evaluate the student’s internship performance:

Completion of agreed upon internship hours; Adherence to expected standards of professional and ethical conduct;
Performance evaluation completed by on-site supervisor (copy available from Psychology Department); Submission of
required written notes and summary reports; Final grade based on completed grading rubric that covers all aspects of
student performance.

Return To: Registrar’s Office, 224 South Hall Mansfield University, Mansfield, PA 16933