SUPERVISION COMPLETED? POPULATION DIRECT HOURS INDIRECT TOTAL HOURS INTERNSHIP DATES HOURS YES NO If NO, list reasons separately & attach. SUPERVISOR SIGNATURE DATE BCT SIGNATURE DATE 4. AGENCY NAME ON- SUPERVISOR NAME / CREDENTIAL ADDRESS PHONE EMAIL STATE/ ZIP + 4 COUNTRY DIRECT HOURS INDIRECT HOURS COMPLETED? POPULATION SUPERVISION TOTAL HOURS INTERNSHIP DATES YES NO If NO, list reasons separately & attach. SUPERVISOR SIGNATURE DATE BCT SIGNATURE DATE REQUIRED INTERNSHIP HOURS SUCCESSFULLY COMPLETED: Total Internship Hours: Total Direct Client Contact Hours: Total Indirect Hours: Total Hours of Supervision: BCT SIGNATURE DATE TRAINEE SIGNATURE DATE North American Drama Therapy Association (NADTA) Alternative Training Learning Contract Statement of Alternative Training Completed
POPULATION DIRECT HOURS INDIRECT SUPERVISION HOURS TOTAL HOURS COMPLETED? INTERNSHIP DATES YES NO If NO, list reasons separately & attach. SUPERVISOR SIGNATURE DATE BCT SIGNATURE DATE 4. AGENCY NAME ON- SUPERVISOR NAME / CREDENTIAL ADDRESS PHONE EMAIL STATE/ ZIP + 4 COUNTRY POPULATION DIRECT HOURS INDIRECT HOURS SUPERVISION TOTAL HOURS COMPLETED? INTERNSHIP DATES YES NO If NO, list reasons separately & attach. SUPERVISOR SIGNATURE DATE BCT SIGNATURE DATE REQUIRED INTERNSHIP HOURS SUCCESSFULLY COMPLETED: Total Internship Hours: Total Direct Client Contact Hours: Total Indirect Hours: Total Hours of Supervision: BCT SIGNATURE DATE TRAINEE SIGNATURE DATE North American Drama Therapy Association (NADTA) Alternative Training Learning Contract Statement of Alternative Training Completed
at-learningcontract-updated-3.15.docx