For Agency-Site Supervisor - please, check one of the following:
Original: No other application exists at Academic-Unit
Continued Practice: An application exists at Academic-Unit and no changes in practice exist from original
Change In Practice: An application exists at Academic-Unit though changes in practice exist for the domain(s) identified below - please, make correction(s) to change(s) only and resubmit to Academic-Unit
Address Line 2
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Papua New Guinea
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
Serbia and Montenegro
Trinidad and Tobago
United Arab Emirates
CTRS Certification Number
Number of full-time CTRS(s) at Agency-Site
* The above named Agency-Site agrees to accept students for internships from Academic-Unit. The Agency-Site recognizes that the Academic-Unit’s goal is to assign students according to their interests and abilities; therefore this is only an application. If such a relationship is perceived, the Academic-Unit will be in contact soon thereafter.
- Please indicate in the spaces provided how the student will be exposed to the following domains while attending your Agency-Site.
1. Individuals Served Comprehension
Opportunities to understand etiologies, symptoms and treatments associated with the populations served at the Agency-Site.
Opportunities to understand the rationale for assessment selection (i.e., reliability, validity, practicality, etc.) and procedures required for selected instruments. Explain how domains are assessed (i.e., cognitive, social, motor,
emotional, leisure background, etc.).
3. Program / Treatment Planning
Opportunities to plan (using outcome oriented goals & behavioral objectives), develop, and promote a variety of recreation activities and programs; gain insight into the many details and facets involved in planning (i.e., normalization principles, inclusion, advocacy, etc.).
4. Implementting Intervention
Opportunities to lead sessions, using various leadership styles / techniques and equipment appropriate for given conditions.
5. Documentation and Evaluation
Opportunities to understand the importance of accountability and be exposed to all documentation required by regulating agencies (i.e., third-party reimbursement, JCAHO, CARF, HCFA, Community Based Regulators, etc.). Methods of documenting & interpreting progress, discharge, and transition plans.
6. Professional Advancement and Public Relations
Opportunities to promote the therapeutic recreation program and agency-site (e.g., press releases, fliers, brochures, attendance at civic and professional group meetings, collaboration, etc.).
Opportunities to observe and become involved in the business affairs of the Agency-Site. Such
experiences include operations and procedures, budgeting and financial planning, bookkeeping and accounting services, and computer operations when available. Opportunities to observe personnel administration related areas such as
employment and promotional practices, staff conferences, and meetings are encouraged. Awareness of “Quality Improvement” components (i.e., utilization review, monitoring, outcome indicators, risk management, infection control, etc.).
8. Additional Information
Opportunities to acquire skills, developing the student intern into the most efficient, effective, and successful therapist possible.
** Additionally, please submit the following to the Academic-Unit Internship Coordinator prior to final approval of the Agency-Site being accepted as an internship Agency-Site:
- Remuneration offered by the Agency-Site (if any; i.e., salary, housing, etc.).
- A description of the mission and goals of the Agency-Site, present services offered, as well as those being developed.
- Resume(s) of Agency-Site Internship Supervisor(s)
Signature of Academic Coordinator