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Site Approval Request
First Name
*
*
Meridian Email
*
Program
*
Has your Request to Initiate Fieldwork been submitted and approved?
*
Are you currently engaged in fieldwork at another site?
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Fieldwork Site Information
Site Name
*
Site Website
*
Site contact person name
*
Site contact person email
*
Site Address line
*
*
*
*
Country
*
Site Phone Number
*
Is this site listed on Meridian's Previously Approved Field Placement Sites list?
*
Is the site one of the following?
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Telehealth and Residency
If you plan to work at this site providing psychotherapy via telehealth, do you live in the same state in which the site is located?
*
A
Yes
B
No
Pre-existing Relationships
Do you have a pre-existing relationship with this site?
*
A
Yes
B
No
SPE (PhD/PsyD Students Only)
If you are a PhD or PsyD student, are you hoping to obtain SPE at this site, towards the 3,000 hours required for psychologist licensure in California?
(Note that SPE is not a requirement for PhD or PsyD fieldwork.)
*
A
Yes
B
No
Date
*
Signature
*
Signature
Submit