Agency Registration Form

Please complete this form to start the affiliation process. Once registration is received and reviewed, the registered Site Representative will be sent a copy of the Affiliation Agreement to Review.

Below is the CSWE qualifications for a Practicum Instructor.

Practicum instructors for BSW students are required to hold at least a BSW degree plus 2 years of post-graduate work experience in social work.

Practicum Instructors for MSW students are required to hold a MSW degree plus 2 years of post-graduate work experience in social work.

Agency Name
Site Representative Name
Site Rep Email
Phone Phone - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Is the agency a private practice?

Is the agency a private practice? No Yes
If Agency is Private Practice please provide Agency website.
Student Type (choose all that apply):

Student Type (choose all that apply): BSW MSW-Foundation MSW-Mental Health & Substance Misuse MSW-Children & Families MSW-Healthcare MSW-Aging MSW-Community & Administrative Practice
Populations Served (choose all that apply):

Populations Served (choose all that apply): Addiction Adolescents Adults Children College/Young Adult Couples Deaf and Hard of Hearing Domestic Violence Eating Disorders Families Female Only Homeless Inpatients LGBTQ+ Low Income Male Only Military Older Adults Persons with Disabilities Severe, Persistent Mental Illness Students
Does the Agency have a CSWE Qualified Practicum Instructor.
(CSWE requires Practicum Instructors to have a Social Work Degree plus 2 years of social work experience)

Does the Agency have a CSWE Qualified Practicum Instructor.
(CSWE requires Practicum Instructors to have a Social Work Degree plus 2 years of social work experience) Yes (if yes, please complete the questions below and add Practicum Instructor Resume) No
Practicum Instructor Name Practicum Instructor Name First Last
Practicum Instructor Email
Practicum Instructor Resume (Required per CSWE and UTA)

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