MENTAL HEALTH COUNSELING CLINICAL - MONTHLY LOG – Please check only one: Practicum Internship I Internship II Student’s Name Year I. HOURS OF DIRECT PROFESSIONAL SERVICE WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 from: from: from: from: from: ACTIVITIES MONTHLY to: to: to: to: to: TOTALS Intakes/Assessments Individual Counseling Group Counseling Family Counseling Consulting/Intervention Career Counseling \ Crisis Intervention In-Home Services Case Management (Direct Service) Other Clinical Work: (Describe) TOTALS II. HOURS OF EDUCATIONAL ACTIVITIES INDIRECT – Individual/Triadic Supervision Live Observation/Supervision or Tape Review Case Conference/Staffing In-Services Consultation Staff Meetings Other: (Describe) TOTALS On-Site Supervisor Signature Student Signature University Supervisor Signature
MENTAL HEALTH COUNSELING – CLINICAL - MONTHLY LOG Please check only one: Practicum Internship I Internship II Student’s Name Year I. HOURS OF DIRECT PROFESSIONAL SERVICE ACTIVITIES WEEK 1 from: to: WEEK 2 from: to: WEEK 3 from: to: WEEK 4 from: to: WEEK 5 from: to: MONTHLY TOTALS Intakes/Assessments Individual Counseling Group Counseling Family Counseling Consulting/Intervention Career Counseling \ Crisis Intervention In-Home Services Case Management (Direct Service) Other Clinical Work: (Describe) TOTALS II. HOURS OF EDUCATIONAL ACTIVITIES – INDIRECT Individual/Triadic Supervision Live Observation/Supervision or Tape Review Case Conference/Staffing In-Services Consultation Staff Meetings Other: (Describe) TOTALS On-Site Supervisor Signature Student Signature University Supervisor Signature