Embed Size (px)
Citation preview
The Department of Counseling – Community Family Life Center
Clinical Hours Documentation Page 1 of 15 Revised: 6/25/2013
Clinical Hours Log – School Counseling Internship Program Instructions: For each activity listed, provide the total number of hours engaged in that activity for each day. For special activities (i.e., seminars, workshops, etc.), list the title as
well as the hours engaged in that activity. Your site supervisor must sign off on each weekly log.
Student Information
Student Name: Banner ID Week of:
Affiliated Practicum / Internship Site Name: Site Supervisor Name:
Professional Experience
Monday Tuesday Wednesday Thursday Friday Saturday Sunday Weekly Total
Cumulative Total
Direct Service
Date
Class/Group Guidance
Individual Counseling
Group Counseling
Consultation
Cumulative Direct Hours:
Indirect Service
Program Management
Professional Activities
Coordination/Referral
In-service/Meetings
Site Supervision
Other:
Cumulative Indirect Hours:
University Supervision
Individual
Group
Cumulative Hours:
Daily Totals:
Site Supervisor Signature: Date: University Supervisor Signature: Date:
The Department of Counseling – Community Family Life Center
Clinical Hours Documentation Page 2 of 15 Revised: 6/25/2013
Clinical Hours Log – School Counseling Internship Program Instructions: For each activity listed, provide the total number of hours engaged in that activity for each day. For special activities (i.e., seminars, workshops, etc.), list the title as
well as the hours engaged in that activity. Your site supervisor must sign off on each weekly log.
Student Information
Student Name: Banner ID Week of:
Affiliated Practicum / Internship Site Name: Site Supervisor Name:
Professional Experience
Monday Tuesday Wednesday Thursday Friday Saturday Sunday Weekly Total
Cumulative Total
Direct Service
Date
Class/Group Guidance
Individual Counseling
Group Counseling
Consultation
Cumulative Direct Hours:
Indirect Service
Program Management
Professional Activities
Coordination/Referral
In-service/Meetings
Site Supervision
Other:
Cumulative Indirect Hours:
University Supervision
Individual
Group
Cumulative Hours:
Daily Totals:
Site Supervisor Signature: Date: University Supervisor Signature: Date:
The Department of Counseling – Community Family Life Center
Clinical Hours Documentation Page 3 of 15 Revised: 6/25/2013
Clinical Hours Log – School Counseling Internship Program Instructions: For each activity listed, provide the total number of hours engaged in that activity for each day. For special activities (i.e., seminars, workshops, etc.), list the title as
well as the hours engaged in that activity. Your site supervisor must sign off on each weekly log.
Student Information
Student Name: Banner ID Week of:
Affiliated Practicum / Internship Site Name: Site Supervisor Name:
Professional Experience
Monday Tuesday Wednesday Thursday Friday Saturday Sunday Weekly Total
Cumulative Total
Direct Service
Date
Class/Group Guidance
Individual Counseling
Group Counseling
Consultation
Cumulative Direct Hours:
Indirect Service
Program Management
Professional Activities
Coordination/Referral
In-service/Meetings
Site Supervision
Other:
Cumulative Indirect Hours:
University Supervision
Individual
Group
Cumulative Hours:
Daily Totals:
Site Supervisor Signature: Date: University Supervisor Signature: Date:
The Department of Counseling – Community Family Life Center
Clinical Hours Documentation Page 4 of 15 Revised: 6/25/2013
Clinical Hours Log – School Counseling Internship Program Instructions: For each activity listed, provide the total number of hours engaged in that activity for each day. For special activities (i.e., seminars, workshops, etc.), list the title as
well as the hours engaged in that activity. Your site supervisor must sign off on each weekly log.
Student Information
Student Name: Banner ID Week of:
Affiliated Practicum / Internship Site Name: Site Supervisor Name:
Professional Experience
Monday Tuesday Wednesday Thursday Friday Saturday Sunday Weekly Total
Cumulative Total
Direct Service
Date
Class/Group Guidance
Individual Counseling
Group Counseling
Consultation
Cumulative Direct Hours:
Indirect Service
Program Management
Professional Activities
Coordination/Referral
In-service/Meetings
Site Supervision
Other:
Cumulative Indirect Hours:
University Supervision
Individual
Group
Cumulative Hours:
Daily Totals:
Site Supervisor Signature: Date: University Supervisor Signature: Date:
The Department of Counseling – Community Family Life Center
Clinical Hours Documentation Page 5 of 15 Revised: 6/25/2013
Clinical Hours Log – School Counseling Internship Program Instructions: For each activity listed, provide the total number of hours engaged in that activity for each day. For special activities (i.e., seminars, workshops, etc.), list the title as
well as the hours engaged in that activity. Your site supervisor must sign off on each weekly log.
Student Information
Student Name: Banner ID Week of:
Affiliated Practicum / Internship Site Name: Site Supervisor Name:
Professional Experience
Monday Tuesday Wednesday Thursday Friday Saturday Sunday Weekly Total
Cumulative Total
Direct Service
Date
Class/Group Guidance
Individual Counseling
Group Counseling
Consultation
Cumulative Direct Hours:
Indirect Service
Program Management
Professional Activities
Coordination/Referral
In-service/Meetings
Site Supervision
Other:
Cumulative Indirect Hours:
University Supervision
Individual
Group
Cumulative Hours:
Daily Totals:
Site Supervisor Signature: Date: University Supervisor Signature: Date:
The Department of Counseling – Community Family Life Center
Clinical Hours Documentation Page 6 of 15 Revised: 6/25/2013
Clinical Hours Log – School Counseling Internship Program Instructions: For each activity listed, provide the total number of hours engaged in that activity for each day. For special activities (i.e., seminars, workshops, etc.), list the title as
well as the hours engaged in that activity. Your site supervisor must sign off on each weekly log.
Student Information
Student Name: Banner ID Week of:
Affiliated Practicum / Internship Site Name: Site Supervisor Name:
Professional Experience
Monday Tuesday Wednesday Thursday Friday Saturday Sunday Weekly Total
Cumulative Total
Direct Service
Date
Class/Group Guidance
Individual Counseling
Group Counseling
Consultation
Cumulative Direct Hours:
Indirect Service
Program Management
Professional Activities
Coordination/Referral
In-service/Meetings
Site Supervision
Other:
Cumulative Indirect Hours:
University Supervision
Individual
Group
Cumulative Hours:
Daily Totals:
Site Supervisor Signature: Date: University Supervisor Signature: Date:
The Department of Counseling – Community Family Life Center
Clinical Hours Documentation Page 7 of 15 Revised: 6/25/2013
Clinical Hours Log – School Counseling Internship Program Instructions: For each activity listed, provide the total number of hours engaged in that activity for each day. For special activities (i.e., seminars, workshops, etc.), list the title as
well as the hours engaged in that activity. Your site supervisor must sign off on each weekly log.
Student Information
Student Name: Banner ID Week of:
Affiliated Practicum / Internship Site Name: Site Supervisor Name:
Professional Experience
Monday Tuesday Wednesday Thursday Friday Saturday Sunday Weekly Total
Cumulative Total
Direct Service
Date
Class/Group Guidance
Individual Counseling
Group Counseling
Consultation
Cumulative Direct Hours:
Indirect Service
Program Management
Professional Activities
Coordination/Referral
In-service/Meetings
Site Supervision
Other:
Cumulative Indirect Hours:
University Supervision
Individual
Group
Cumulative Hours:
Daily Totals:
Site Supervisor Signature: Date: University Supervisor Signature: Date:
The Department of Counseling – Community Family Life Center
Clinical Hours Documentation Page 8 of 15 Revised: 6/25/2013
Clinical Hours Log – School Counseling Internship Program Instructions: For each activity listed, provide the total number of hours engaged in that activity for each day. For special activities (i.e., seminars, workshops, etc.), list the title as
well as the hours engaged in that activity. Your site supervisor must sign off on each weekly log.
Student Information
Student Name: Banner ID Week of:
Affiliated Practicum / Internship Site Name: Site Supervisor Name:
Professional Experience
Monday Tuesday Wednesday Thursday Friday Saturday Sunday Weekly Total
Cumulative Total
Direct Service
Date
Class/Group Guidance
Individual Counseling
Group Counseling
Consultation
Cumulative Direct Hours:
Indirect Service
Program Management
Professional Activities
Coordination/Referral
In-service/Meetings
Site Supervision
Other:
Cumulative Indirect Hours:
University Supervision
Individual
Group
Cumulative Hours:
Daily Totals:
Site Supervisor Signature: Date: University Supervisor Signature: Date:
The Department of Counseling – Community Family Life Center
Clinical Hours Documentation Page 9 of 15 Revised: 6/25/2013
Clinical Hours Log – School Counseling Internship Program Instructions: For each activity listed, provide the total number of hours engaged in that activity for each day. For special activities (i.e., seminars, workshops, etc.), list the title as
well as the hours engaged in that activity. Your site supervisor must sign off on each weekly log.
Student Information
Student Name: Banner ID Week of:
Affiliated Practicum / Internship Site Name: Site Supervisor Name:
Professional Experience
Monday Tuesday Wednesday Thursday Friday Saturday Sunday Weekly Total
Cumulative Total
Direct Service
Date
Class/Group Guidance
Individual Counseling
Group Counseling
Consultation
Cumulative Direct Hours:
Indirect Service
Program Management
Professional Activities
Coordination/Referral
In-service/Meetings
Site Supervision
Other:
Cumulative Indirect Hours:
University Supervision
Individual
Group
Cumulative Hours:
Daily Totals:
Site Supervisor Signature: Date: University Supervisor Signature: Date:
The Department of Counseling – Community Family Life Center
Clinical Hours Documentation Page 10 of 15 Revised: 6/25/2013
Clinical Hours Log – School Counseling Internship Program Instructions: For each activity listed, provide the total number of hours engaged in that activity for each day. For special activities (i.e., seminars, workshops, etc.), list the title as
well as the hours engaged in that activity. Your site supervisor must sign off on each weekly log.
Student Information
Student Name: Banner ID Week of:
Affiliated Practicum / Internship Site Name: Site Supervisor Name:
Professional Experience
Monday Tuesday Wednesday Thursday Friday Saturday Sunday Weekly Total
Cumulative Total
Direct Service
Date
Class/Group Guidance
Individual Counseling
Group Counseling
Consultation
Cumulative Direct Hours:
Indirect Service
Program Management
Professional Activities
Coordination/Referral
In-service/Meetings
Site Supervision
Other:
Cumulative Indirect Hours:
University Supervision
Individual
Group
Cumulative Hours:
Daily Totals:
Site Supervisor Signature: Date: University Supervisor Signature: Date:
The Department of Counseling – Community Family Life Center
Clinical Hours Documentation Page 11 of 15 Revised: 6/25/2013
Clinical Hours Log – School Counseling Internship Program Instructions: For each activity listed, provide the total number of hours engaged in that activity for each day. For special activities (i.e., seminars, workshops, etc.), list the title as
well as the hours engaged in that activity. Your site supervisor must sign off on each weekly log.
Student Information
Student Name: Banner ID Week of:
Affiliated Practicum / Internship Site Name: Site Supervisor Name:
Professional Experience
Monday Tuesday Wednesday Thursday Friday Saturday Sunday Weekly Total
Cumulative Total
Direct Service
Date
Class/Group Guidance
Individual Counseling
Group Counseling
Consultation
Cumulative Direct Hours:
Indirect Service
Program Management
Professional Activities
Coordination/Referral
In-service/Meetings
Site Supervision
Other:
Cumulative Indirect Hours:
University Supervision
Individual
Group
Cumulative Hours:
Daily Totals:
Site Supervisor Signature: Date: University Supervisor Signature: Date:
The Department of Counseling – Community Family Life Center
Clinical Hours Documentation Page 12 of 15 Revised: 6/25/2013
Clinical Hours Log – School Counseling Internship Program Instructions: For each activity listed, provide the total number of hours engaged in that activity for each day. For special activities (i.e., seminars, workshops, etc.), list the title as
well as the hours engaged in that activity. Your site supervisor must sign off on each weekly log.
Student Information
Student Name: Banner ID Week of:
Affiliated Practicum / Internship Site Name: Site Supervisor Name:
Professional Experience
Monday Tuesday Wednesday Thursday Friday Saturday Sunday Weekly Total
Cumulative Total
Direct Service
Date
Class/Group Guidance
Individual Counseling
Group Counseling
Consultation
Cumulative Direct Hours:
Indirect Service
Program Management
Professional Activities
Coordination/Referral
In-service/Meetings
Site Supervision
Other:
Cumulative Indirect Hours:
University Supervision
Individual
Group
Cumulative Hours:
Daily Totals:
Site Supervisor Signature: Date: University Supervisor Signature: Date:
The Department of Counseling – Community Family Life Center
Clinical Hours Documentation Page 13 of 15 Revised:
Clinical Hours Log – School Counseling Internship Program Instructions: For each activity listed, provide the total number of hours engaged in that activity for each day. For special activities (i.e., seminars, workshops, etc.), list the title as
well as the hours engaged in that activity. Your site supervisor must sign off on each weekly log.
Student Information
Student Name: Banner ID Week of:
Affiliated Practicum / Internship Site Name: Site Supervisor Name:
Professional Experience
Monday Tuesday Wednesday Thursday Friday Saturday Sunday Weekly Total
Cumulative Total
Direct Service
Date
Class/Group Guidance
Individual Counseling
Group Counseling
Consultation
Cumulative Direct Hours:
Indirect Service
Program Management
Professional Activities
Coordination/Referral
In-service/Meetings
Site Supervision
Other:
Cumulative Indirect Hours:
University Supervision
Individual
Group
Cumulative Hours:
Daily Totals:
Site Supervisor Signature: Date: University Supervisor Signature: Date:
The Department of Counseling – Community Family Life Center
Clinical Hours Documentation Page 14 of 15 Revised:
Clinical Hours Log – School Counseling Internship Program Instructions: For each activity listed, provide the total number of hours engaged in that activity for each day. For special activities (i.e., seminars, workshops, etc.), list the title as
well as the hours engaged in that activity. Your site supervisor must sign off on each weekly log.
Student Information
Student Name: Banner ID Week of:
Affiliated Practicum / Internship Site Name: Site Supervisor Name:
Professional Experience
Monday Tuesday Wednesday Thursday Friday Saturday Sunday Weekly Total
Cumulative Total
Direct Service
Date
Class/Group Guidance
Individual Counseling
Group Counseling
Consultation
Cumulative Direct Hours:
Indirect Service
Program Management
Professional Activities
Coordination/Referral
In-service/Meetings
Site Supervision
Other:
Cumulative Indirect Hours:
University Supervision
Individual
Group
Cumulative Hours:
Daily Totals:
Site Supervisor Signature: Date: University Supervisor Signature: Date:
The Department of Counseling – Community Family Life Center
Clinical Hours Documentation Page 15 of 15 Revised:
Clinical Hours Log – School Counseling Internship Program Instructions: For each activity listed, provide the total number of hours engaged in that activity for each day. For special activities (i.e., seminars, workshops, etc.), list the title as
well as the hours engaged in that activity. Your site supervisor must sign off on each weekly log.
Student Information
Student Name: Banner ID Week of:
Affiliated Practicum / Internship Site Name: Site Supervisor Name:
Professional Experience
Monday Tuesday Wednesday Thursday Friday Saturday Sunday Weekly Total
Cumulative Total
Direct Service
Date
Class/Group Guidance
Individual Counseling
Group Counseling
Consultation
Cumulative Direct Hours:
Indirect Service
Program Management
Professional Activities
Coordination/Referral
In-service/Meetings
Site Supervision
Other:
Cumulative Indirect Hours:
University Supervision
Individual
Group
Cumulative Hours:
Daily Totals:
Site Supervisor Signature: Date: University Supervisor Signature: Date:
