Request for Placement Approval

PSYC 491, Field Experience in Psychology

Use this form to request approval of a placement that is not in the list of available sites for PSYC 491. Submit this form to Ms. Stephanie McWilliams by placing it in her mailbox in the Psychology Department main office (room 1124 LSB) or by sending the information requested below in an e-mail message to: srmcwilliams@mail.wvu.edu

Your Name Your Name * First Last
WVU Mix Email *
Name of organization you would like to with: *
Location of organization: *
Brief description of the goals of the organization:
Brief description of the activities you would engage in during this placement:
Would you be working with children (under age 18)? *

Would you be working with children (under age 18)? Yes No
Name of the person who would supervise you: Name of the person who would supervise you: * First Last
Their position in the organization:
Their contact information: Phone Their contact information: Phone * - ### - ### ####
Their contact information: Email *
Description of their educational background and training (degrees earned, licenses held, etc.):
Degree of potential supervisor *

Degree of potential supervisor Ph.D. Psy.D. Ed.D. Masters Degree Bachelors Degree Other Other
Feel free to include any other relevant information.
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