University of Arkansas at Little Rock

Psychology Department

Internship Mentor Contract

Internship Institution: __________________________________________

Internship Mentor Name: _________________________________________

Internship Address:

Other Intern Mentor contact information:

Phone: _________________

Daytime _________________

Email: __________________

Intern Name: ______________________________________________

Date: ____________________

I’d like to thank you for agreeing to serve as a host for a UALR psychology student intern. Your intern will sign a contract with a supervising UALR faculty member agreeing to the stipulated requirements for class credit as found in the Internship Site Application or online via http://www.ualr.edu/psycinfo/stud1a.html. Any other specific requirements should be negotiated and agreed upon as a component of the mentor-intern relationship.

Sincerely,

David F. Mastin, Ph.D.

UALR Psychology Department Internship Coordinator

(501) 371-7548

As an Internship Mentor I agree to:

1.      To provide a professional and educational experience as described in the application form for my site.

2.      To provide regular supervision.

3.      To provide mid-semester feedback to the supervising faculty. This may be informal in the form of a phone call or email or formal in the form of the Mid-Term Internship Mentor Feedback Form (MTIMFF) to be provided by the intern or may be downloaded via http://www.ualr.edu/~psycinfo/paper1a.html.

4.      Completion of the End-Term Internship Mentor Feedback Form (ETIMFF) provided by the student or may be downloaded via http://www.ualr.edu/~psycinfo/paper1a.html.

Internship Mentor Signature ________________________________________________

Date _____________