EmailMe Form - Site Suggeston: Affiliation Agreement

Site Suggeston: Affiliation Agreement

If there is a site in your area that does not have an Affiliation Agreement in Meditrek, and you have reached out to the site with initial interest in securing a placement there, you can use this form to request that we attempt to establish an Affiliation Agreement. An early request may help increase your chances of placement at a given site and may speed up the process once you apply for Field Experience.

**Instructions are available in the Site Search Resources area of the Field Experience Website.

Name of Site (e.g. The Center for Relational Living) *
Site Contact to Sign Agreement (e.g. Suzy Smith; Director of Human Resources) *

Name

Title or Position

(Ask for this detail when you reach out to the site)
Email of Site Contact (e.g. Suzy.smith@notarealemail.org) *
Web Site (Include if available; e.g. www.***.org)
Phone (Include if available)
### - ### - ####
Address (Add as much detail as you have available)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
I have contacted this site and determined that a) it is an appropriate site for counseling students and b) they will consider accepting a field experience student *
Yes
The site contact is aware that a representative from Walden University will be reaching out to establish an Affiliation Agreement
Yes
No
I affirm that it is okay to attach my name to this request when contacting the site
Yes
No
Student's Name (e.g. Johnny Appleseed) *
First Last
Student ID Number (e.g. A000000) *
Student's Program of Study *
Clinical Mental Health Counseling
School Counseling
Marriage, Couple, and Family Counseling
Counselor Education and Supervision
In what quarter do you intend to start this field experience? (e.g. Summer 2020)
Any additional details about the site you would like us to know (Not required)

Name
Title or Position