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Revised January 2017 of 21

TABLE OF CONTENTS

Item Page Deadline

Internship Planning Process 2-3

Internship Eligibility Form

4 If beginning in Fall semester- March 1st; If beginning in the Spring semester – October 1st; If beginning in the Summer March 1st

Internship Agreement 5-8 If beginning in Fall semester- July 1st; If beginning in the Spring semester – December 1st; If beginning in the Summer - May 1st

Assigned Supervisor Qualifications Form 9

Reporting: Weekly Internship Log and Activity Report 10 Due weekly in internship class

CMHC Internship Skill Evaluation 11-17 Due at the end of Internship I and Internship II

CMHC Internship Professional Behavior Evaluation Form 18

Assessment of the Clinical Experience 19-20

Internship Completion Form 21

For information contact:

Dr. Lynne Guillot-Miller Coordinator of the Master’s Degree Program in Clinical Mental Health Counseling

OR

Dr. Steve Rainey Master’s Practicum and Internship Coordinator

310 White Hall, College of Education, Kent State University, Kent, OH 44242

(330) 672-2662 * * * * FAX (330) 672-2472

College of Education, Health, & Human Services Counselor Education and Supervision (CES) Program

CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP MANUAL


KENT STATE UNIVERSITY CLINICAL MENTAL HEALTH COUNSELING PROGRAM

INTERNSHIP IN CLINICAL MENTAL HEALTH COUNSELING

INTERNSHIP PLANNING PROCESS The internship experience represents the culmination of formal academic training in the Clinical Mental Health Counseling program. It is the opportunity students have to assume the role of professional counselor-in-training (i.e., “Counselor Trainee”) and to provide clinical services within a community agency, school, hospital, private group practice, or college counseling facility under appropriate supervision. The internship experience is also an “opportunity for the student to become familiar with a variety of professional activities and resources in addition to direct service (e.g., record keeping, assessment instruments, supervision, information and referral, in-service and staff meetings)” (CACREP, 2009, p. 16). According to Ohio counselor licensure law, students can only practice as “Counselor Trainees” when they are enrolled in either counseling practicum or internship courses and are receiving appropriate face-to-face supervision. The Counselor Education and Supervision (CES) Program further requires that all Clinical Mental Health Counseling students preparing for internship register with the Ohio Counselor, Social Worker, and Marriage and Family Therapist Board (Ohio CSW&MFT Board) as a “Counselor Trainee” prior to beginning internship. The internship experience, therefore, serves as a “testing ground” of sorts. Students have the opportunity to test the academic course work and formal training received thus far and students are themselves challenged to practice, in the role of Counselor Trainee/Intern, the counseling theories, techniques, and procedures learned in their program.

Internship is undertaken at the conclusion of the student’s program, with no more than 6 credit hours remaining to complete the 60-credit hour master’s degree in Clinical Mental Health Counseling (excluding the 6 credit hours required for internship). The internship is undertaken over two semesters (or one semester and one summer term) and therefore students will be enrolled for 3 credit hours of internship for each of the two semesters of their internship experience.

All CACREP core area courses (as listed on the Clinical Mental Health Counseling prospectus) need to be completed prior to the start of internship. Four additional courses are also prerequisites to internship:

CES 6/77628: Diagnosis in Counseling CES 6/78130: Psychopathology for Counselors

CES 6/77492: Practicum I CES 6/77592: Practicum II

Successful completion of all CACREP core area courses and the four courses listed above must be verified on the student’s academic transcript.

It is important that each student identifies and selects an internship setting that suits his or her learning requirements. In order to accomplish this, considerable planning and careful preparation must be completed before the student actually begins the internship experience. The internship experience must provide the student with opportunities to engage in clinical counseling services; that is, the student must engage in the diagnosis and treatment of mental disorders, under the supervision of a licensed Professional Clinical Counselor (PCC) who has the supervisory endorsement of the Ohio CSW&MFT Board (PCC-S credential). Clinical services provided during internship include, but are not limited to, screening clients for treatment eligibility, conducting comprehensive assessments, determining DSM diagnoses, providing appropriate treatment interventions to clients, and constructing individualized treatment plans. The clinical nature of the internship experience fulfills licensure eligibility requirements in the state of Ohio. The Clinical Mental Health Counseling internship experience must therefore be undertaken and completed in Ohio. Once a potential internship site has been located by a student, the Master’s Practicum and Internship Coordinator verify the appropriateness of the setting and supervision prior to the student beginning his or her internship experience (this usually entails telephone contact with the proposed site supervisor or appropriate representative of the proposed internship site).

What follows is a step-by-step process for students to follow in identifying and securing an internship setting and experience. As a student, it is your responsibility to begin the process early (i.e., at least one full semester prior to the beginning of the internship experience). This means completing the Internship Eligibility Form and meeting with your CES faculty advisor to review and sign it. Your careful attention to the Internship Eligibility Form will ensure that the internship location process begins smoothly and will help ensure that you identify an appropriate setting. If you have questions about completing the internship materials, contact your CES faculty advisor or the Master’s Practicum and Internship Coordinator.

Step-by-Step Directions 1. Complete Internship Eligibility Form: The first step of the internship application process is completing the Internship Eligibility Form, found within this

Internship Manual, with the two (2) necessary accompanying materials: (a) current academic transcript and (b) Student Profile with accompanying documents. Your completion of this form will help to clarify your needs and goals for the internship experience and will help identify an appropriate internship placement. You will need to have completed the Internship Eligibility Form (and the two necessary accompanying materials) before meeting with your CES faculty advisor. His or her signature on the form indicates that you are academically ready to begin the internship experience at the start of the semester (or summer term) you have indicated.

2. Meet with CES Faculty Advisor: The next step in the process of locating an internship site is meeting with your CES faculty advisor and discussing your

Internship Eligibility Form. It is recommended that you schedule an appointment and meet face-to-face with your CES faculty advisor early in the semester prior to the beginning of your proposed internship experience. Once your faculty advisor has reviewed the Internship Eligibility Form, obtain his/her signature, and make a copy of the form for yourself.

3. Submit Completed Internship Eligibility Form to Master’s Practicum & Internship Coordinator: A copy of the Internship Eligibility Form, signed and dated by both you and your CES faculty advisor, along with the two necessary accompanying materials (i.e., current academic transcript and Student Profile), are due to the Master’s Practicum and Internship Coordinator by the date listed in the Table of Contents of this document. Failure to submit necessary paperwork by the deadlines specified in the Table of Contents may delay (by as much as an entire semester) the commencement of your internship experience.

4. Obtain List of Potential Internship Sites in Ohio: A list of potential internship sites in Ohio (primarily Northeast Ohio) is available in the CES office, 310 White Hall. It is the student’s responsibility to contact and secure an internship site and the site must be in Ohio. Your CES faculty advisor and the Master’s Practicum and Internship Coordinator can assist in identifying and recommending particular sites. However, it will be your responsibility to initiate contact with potential internship sites, schedule interviews, and finalize the internship agreement.


5. Contact Potential Internship Sites: Once you have identified several potential internship sites in Ohio (as a result of conferring with your CES academic advisor and/or the Master’s Practicum and Internship Coordinator), it is recommended that you begin making telephone calls and scheduling appointments early in the process (i.e., at the very beginning of the semester prior to the start of your proposed internship). When you call each agency/organization, ask to speak directly with the clinical director and/or internship coordinator; inquire about the specific clinical services provided by each agency, school, or hospital that a counseling intern would be able to offer (e.g., psychological testing, diagnostic assessment, treatment planning, conducting individual counseling sessions so as to accrue a minimum of 80 individual direct or face-to-face clock hours); and request an on-site interview for a possible internship experience. It is strongly recommended that you make the initial contact by telephone and only use email communication to follow-up a voice mail message left for the contact person or when advised to use email by the contact person. In addition, do not base an internship agreement on a telephone interview! Schedule an on-site interview with the agency contact person and meet directly with this person. Take a copy of this Clinical Mental Health Counseling Internship Manual and your resume with you. Keep track of the agencies and persons you contact and be certain you know with whom you are speaking and his/her title, credentials (graduate degree, professional license), and position at the agency.

6. Interview Guidelines: Once an interview has been scheduled, arrive on time for the scheduled interview. Do not be a “no show”! Remember, you are representing the Clinical Mental Health Counseling program at KSU. Take with you to the interview a copy of your current resume and a copy of this Clinical Mental Health Counseling Internship Manual to leave with the person with whom you will be interviewing. Provide that person with the name and telephone number of the Master’s Practicum and Internship Coordinator. Clarify that individual and face-to-face weekly supervision will need to be provided by a licensed Professional Clinical Counselor (PCC-S) who has the supervisory endorsement of the Ohio CSW&MFT Board, and who is an employee (part-time, full-time, or contracted with the agency) of the agency, school, or hospital where you will be conducting your internship. Follow-up the in- person interviews you have had with telephone calls to inquire about the status of your request for an internship experience. Don’t wait for them to call you! Be persistent but do not be a “pest.”

7. Securing the Internship Site: It is strongly recommended that students only accept an offer of a counseling internship once they have completed a face-to- face interview with the appropriate person at the internship site. If you have received more than one offer of a counseling internship, it is imperative that you inform the site(s) whose offer you will not be accepting that you have accepted an offer at another internship site and therefore will be declining that offer. Furthermore, if you have verbally accepted an internship offer, you need to follow-through and finalize the internship agreement in writing. If for various reasons you need to decline an offer that you initially accepted, it is imperative that you speak directly with the person who offered you the internship position and explain your reason(s) for reneging on the verbal agreement you made earlier. Remember that you are not only representing the Clinical Mental Health Counseling program at KSU, you are also engaging in professional behavior and therefore making impressions to prospective employers.

8. Completing Necessary Paperwork: Upon securing an internship site, meet with the agency or school representative where you will be undertaking your internship experience to complete necessary paperwork. There are two CES Program forms that need to be completed (including signatures) and there is one form of the Ohio CSW&MFT Board that needs to be completed. All KSU Clinical Mental Health Counseling students undertaking their internship must be registered with the Ohio CSW & MFT Board as a Counselor Trainee for the entirety of their internship. Students must also turn in a copy of their Professional Liability Insurance to the CES Program. A. CES Program Internship Forms and Documents (see item 9 below):

1. Internship Agreement signed by agency or school representative and student 2. Assigned Supervisor Qualifications form 3. Proof of Professional Liability Insurance Policy

B. Ohio CSW&MFT Board Form (see item 11 below): Follow the steps outlined by the Ohio CSW&MFT board for Counselor Trainees (accessible on the Board’s website: http://www.cswmft.ohio.gov under “Counselor” tab). This application (if not completed on-line), once completed by the internship student and the internship site supervisor, needs to be submitted by the internship student directly to the Ohio CSW&MFT Board.

9. Submitting all Necessary Paperwork to the Master’s Practicum and Internship Coordinator: Please submit to the Master’s Practicum and Internship Coordinator the following two forms and one document: (1) the original (not a faxed copy) CES Internship Agreement form, and (2) the original (not a faxed copy) CES Assignment of Supervisor and Supervisor Qualifications Form and proof of your Professional Liability Insurance Policy. These two forms (complete, including signatures) and proof of your Professional Liability Insurance Policy need to be on file by the date listed in the Table of Contents of this document. Failure to submit necessary paperwork by the deadlines specified in the Table of Contents may delay (by as much as an entire semester) the commencement of your internship experience.

10. Enrollment in Clinical Mental Health Counseling Internship Course: The Master’s Practicum and Internship Coordinator will clear students to enroll in CES 67792: Internship I: Clinical Mental Health Counseling (3 credit hours) the first semester of internship and CES 67892: Internship II: Clinical Mental Health Counseling (3 credit hours) the second semester of internship. Enrollment will only take place when all required paperwork has been completed and submitted to the Master’s Practicum and Internship Coordinator. Once enrolled in the first semester of the Clinical Mental Health Counseling Internship course, students will have the first two weeks of the first semester of their internship to verify to the Master’s Practicum and Internship Coordinator that they have earned a “Satisfactory” grade in their Practicum 2 course. If such a grade has not been earned in the first two weeks of the first semester of Internship I, the student will be withdrawn from Internship I.

11. Professional Counselor Trainee Application: Follow the steps outlined by the Ohio CSW&MFT board for Counselor Trainees (accessible on the Board’s website: http://www.cswmft.ohio.gov under “Counselor” tab). This application (if not completed on-line), once completed by the internship student and the internship site supervisor, needs to be submitted by the internship student directly to the Ohio CSW&MFT Board. If approved by the Board, the student will be registered on the Board’s website as a “Counselor Trainee.” To verify status as a Counselor Trainee, please go to the Board’s website at http://www.cswmft.ohio.gov and click on “License Verification” (although “Counselor Trainee” is not a license). Please print a copy of your Counselor Trainee verification from the Board website and present this to the internship instructor on the first day of internship class each semester.

12. Completing State and Federal Criminal Background Checks: The Ohio CSW&MFT Board requires that all applicants for the Counselor Trainee status complete state and federal criminal background checks. Results need to be sent directly to the Ohio CSW&MFT Board and the Ohio CSW&MFT Board needs to be the recipient of the results (i.e., a copy of results will not be accepted by the Board). Please consult the instructions on the licensure Board’s website for completing the Ohio Bureau of Criminal Identification and Investigation (BCI&I) and the Federal Bureau of Investigation (FBI) criminal records check.

http://www.cswmft.ohio.gov/






INTERNSHIP ELIGIBILITY FORM

Date Submitted to Master’s Practicum & Internship Coordinator: Master’s Practicum & Internship Coordinator’s Initials:

This form is due March 1 if starting Fall semester, October 1 if starting Spring semester, or March 1, if starting Summer term. Read all directions carefully before completing the form. Type or print neatly all information needed.

I. Identifying Information

Name: Banner ID#

Current Postal Mailing Address:

Home Telephone Number: Other Phone Number:

E-Mail Address:

Semesters and Year(s) When Internship will be Undertaken (please check appropriate combination):

Fall and Spring (approx. 36 weeks total, including Fall final exam week, 4-week winter break, and Spring break)

Spring and Summer (approx. 31 weeks total, including Spring break, Spring final exam week, 4-week spring/summer intersession,

and 10 week summer term)

Summer and Fall (approx. 26 weeks total, including 10-week summer term, one week in-between summer term and start of Fall

semester)

Month and Year of Expected Graduation:

II. Attach a Current Academic Transcript This is available from the Registrar’s Office or FlashLine and should include all graduate courses completed to this date.

III. Clinical Mental Health Counseling Courses Currently in Progress List all the courses in which you are currently enrolled. Include courses you are now taking and for which you have not received a final grade. You will need to verify the completion of all CACREP core area courses, as well as the additional internship prerequisite courses identified in this Internship Manual, before you can begin your internship experience.

1) 2) 3)

IV. Clinical Mental Health Counseling Courses To Be Completed List all the course work you plan to complete before graduation. Students cannot begin the internship experience if more than six (6) credit hours remain (excluding the 6 credit hours of CMHC Internship) on their Clinical Mental Health Counseling prospectus.

V. Student Profile or Résumé This information should be composed on a separate and printed double-spaced document addressing the following areas as they relate to your aspirations in the profession of counseling.

1. Preferred internship setting, population served, and overall experience. Please describe the type of internship setting, type of population served, and

overall internship experience that you prefer. Please discuss how your proposed internship experience will be clinical in nature (i.e., include the diagnosis and treatment of mental disorders under clinical supervision).

2. Experience relevant to Clinical Mental Health Counseling: Describe paid or volunteer activities through which you have gained experience helpful to a counseling career. This is general, so consider any experiences that demonstrate your potential to work with people, such as a residence hall advisor, crisis hotline volunteer, or other related activities. You may attach a copy of your resume.

3. Post-graduation plans: Indicate your employment aspirations, plans for further study, or other expectations that have a bearing on your future as a professional counselor.

4. Describe what goals or educational objectives you hope to accomplish through the internship experience. What strengths do you take with you into this internship experience? What areas are you aware of that need further work? Specify if you are interested in certain client groups or specific treatment approaches.

Student’s Signature: Date:

CES Faculty Advisor’s Signature: Date:

Accompanying Materials Needed: (a) Current Academic Transcript of graduate studies and (b) Completed Student Profile or Résumé.




CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP AGREEMENT

Directions: This agreement is to verify for Kent State University (hereinafter referred to as “University”), the Internship Site (also referred to as “Agency”), and the student Intern (also referred to as “Counselor Trainee/Intern”) the expectations of the internship experience and to document that all parties have agreed to take part in this experience. The Internship Site (located in Ohio), the University, and the student Intern should receive a copy of the completed and signed form for their records. This agreement MUST be completed and signed by all appropriate parties, and the original agreement submitted (all pages of the original agreement) to the Master’s Practicum and Internship Coordinator by July 1, if starting Fall semester; December 1, if starting Spring semester; or May 1, if starting Summer term.

This agreement between the Counselor Education and Supervision (CES) Program at Kent State University and

of , Ohio, is for the purpose of identifying (Agency Name) (City)

responsibilities of all parties throughout the Clinical Mental Health Counseling Internship of

(Name of CES Clinical Mental Health Counseling Student)

while he/she is enrolled in and attending in person the weekly Clinical Mental Health Counseling Internship course for

. (Semesters and Year[s] of Internship Experience and Internship Experience Course Attendance)

General Policies

1. The central purpose of this agreement is the formal education of students in preparation for practice as licensed Professional Counselors.

2. This agreement shall remain in effect for the duration of the student’s internship experience for the time period indicated at the agency specified above. Termination of this agreement prior to the successful completion of internship requires the consultation of the assigned internship site supervisor, agency representative, Internship Instructor, Master’s Practicum and Internship Coordinator at the University, and the student. Similar consultation is required if the student secures an additional internship site.

3. The internship experience is typically a voluntary arrangement with no financial remuneration required by the University or Agency for services provided

while fulfilling internship duties; however, some agencies may offer stipends to interns.

4. The internship experience is to be undertaken and completed at an appropriate setting in Ohio and all Counselor Trainees/Interns must be registered with the Ohio CSW&MFT Board as “Counselor Trainees” for the entirety of internship. Out-of-state internship experiences are not acceptable and weekly in- person attendance in the Clinical Mental Health Counseling Internship course is required.

5. Duration of internship is typically for two academic semesters (or one semester and a summer term), exclusive of vacations. Students may continue to practice as a Counselor Trainee/Intern at the internship setting during academic breaks at the university (e.g., spring break, winter break, spring/summer intersession) only as long as the student remains continuously enrolled in a section of Clinical Mental Health Counseling Internship. Internship undertaken for the Fall and Spring semesters is approximately 36 weeks; for Spring semester and summer term, the length of internship is approximately 31 weeks; and for summer term and Fall semester, the length of internship is approximately 26 weeks.

6. Once all necessary paperwork and completed forms have been submitted to the Master’s Practicum and Internship Coordinator by the deadline specified in

this Manual, and the Master’s Practicum and Internship Coordinator has determined (in consultation with agency representative) that the proposed internship site and experience are appropriate for fulfilling both CES Clinical Mental Health Counseling program and state licensure eligibility requirements, the student will be cleared to enroll for 3 credit hours in the Clinical Mental Health Counseling Internship course for each semester he/she is undertaking the internship experience. Students will be withdrawn from the Clinical Mental Health Counseling Internship course within the first two weeks of the first semester of internship if they have yet to earn a Satisfactory grade for Practicum 2.

7. Internship hours shall be in accordance with agency work hours and shall total a minimum of 20 clock hours per week for a minimum total of 600 clock hours at the conclusion of the internship experience. Of the 600 clock hours needed, a minimum of 240 clock hours must be in direct and face-to-face service to clients (and a minimum of 80 clock hours must be in individual face-to-face service to clients).

8. Weekly face-to-face individual supervision (approximately 1 hour/week) must be provided by a licensed Professional Clinical Counselor who has the supervisory endorsement of the Ohio Counselor, Social Worker, and Marriage and Family Therapist Board (Ohio SWMFT Board), and who is an employee (part-time, full-time, or contracted with the agency) of the agency, school, or hospital where the Clinical Mental Health Counseling student is undertaking his/her internship experience. One hour of individual supervision must be provided for every 20 hours of internship activity. Therefore, a 600-hour internship would include a minimum of 30 hours of face-to-face individual supervision, with an additional hour for every 20 hours of internship activity beyond the 600 clock hour minimum. It is strongly recommended that a set day/time for weekly individual supervision be established.

9. The internship experience must be clinical in nature. That is, Clinical Mental Health Counseling interns must have the opportunity to engage in the diagnosis and treatment of mental disorders. Such services include, but are not limited to, psychological testing, diagnostic assessment, the provision of appropriate counseling interventions, and developing comprehensive and individualized treatment plans. This fulfills licensure eligibility requirements as a Professional Counselor in Ohio.


10. Students cannot begin accruing clock hours towards internship requirements until all agreement forms have been signed by all parties (i.e., CES faculty advisor, site/clinical supervisor, Master’s Practicum and Internship Coordinator, and student intern), have been submitted in a timely fashion (according to deadlines specified in this Internship Manual) to the Master’s Practicum and Internship Coordinator, and the internship setting and experience have been determined as appropriate by the Master’s Practicum and Internship Coordinator. Students may begin accruing direct client contact hours on the first day of the academic semester or summer term in which the student is enrolled for internship. Students may participate in agency orientation activities excluding any client contact prior to the beginning of the academic semester. Vacations and holidays shall be observed according to the University calendar, unless otherwise agreed upon by the University representative, Agency, and student.

11. Students who are engaged in Clinical Mental Health Counseling internship-related activities and are enrolled in the Clinical Mental Health Counseling internship course, are required to attend in-person weekly internship class sessions for the duration of their internship experience as determined by the time period indicated on the first and last pages of this agreement. Because the Clinical Mental Health Counseling Internship course is not an on-line or distance course, attendance by video conferencing or by using any other form of electronic communication is not acceptable.

Responsibilities of the University

The University agrees to:

1. Assume full responsibility for the administrative duties associated with the academic requirements of the Clinical Mental Health Counseling Internship, including approval of the Internship Site and experience, maintaining on-going and direct communication with Agency representatives, ensuring that Student Interns are academically ready to begin the Internship experience, and grading.

2. Provide information regarding the CES Clinical Mental Health Counseling program and curriculum in order that the Agency may properly plan and execute

task assignments and supervision. Specifically included are student data, university calendar, student handbook, and the Clinical Mental Health Counseling Internship Manual.

3. Designate one CES faculty member each academic semester who will be the Internship Instructor for the Student and who will communicate directly with

the internship site supervisor (by telephone contact and possibly an internship site visit). The Instructor will lead and facilitate weekly Clinical Mental Health Counseling Internship class sessions (2.5 hours/week) to which all student interns will be required to attend in-person, and will be available for consultation with the internship site supervisor and students for the duration of their internship experience. The role of the Internship Instructor and the Master’s Practicum and Internship Coordinator will be that of a consultant alone; the designated internship site supervisor will assume legal responsibility for all clients seen by the student intern.

Responsibilities of the Agency

The Agency agrees to:

1. Designate one staff person as internship site supervisor with appropriate graduate degree and an independent mental health license. This person will be an employee (part-time, full-time, or contracted with the agency) of the Agency where the internship will be conducted. Internship site supervisors of all counseling interns must hold the license of Professional Clinical Counselor (PCC) in Ohio and must have the supervisory endorsement of the Ohio CSW&MFT Board (i.e., PCC-S designation) at the beginning and for the duration of the student’s internship experience. The designated internship site supervisor will assume legal responsibility for the welfare of all clients seen by the student intern.

2. Develop work assignments and tasks for the Counselor Trainee/Intern commensurate with the CES Program objectives, in consultation with the CES Internship Instructor and Master’s Practicum and Internship Coordinator. Furthermore, opportunities must be present for the student intern to become familiar with a variety of professional activities in addition to direct service (e.g. record keeping, supervision, information and referral, in-service and staff meetings).

3. The opportunity for the Counselor Trainee/Intern to gain experience in the use of a variety of professional resources such as assessment instruments, print

and non-print media, professional literature, and research will be provided.

4. Ensure that at least 240 clock hours are devoted to direct, face-to-face service to clients, and that of these 240 hours, a minimum 80 clock hours are devoted to providing individual counseling services to clients and a minimum of 16 hours co-facilitating groups.. Furthermore, the agency agrees to offer audio/video recording access or, in the absence of such recording, live observation or co-counseling. A maximum of 10 direct client contact hours (of the minimum 240 required) can be obtained in telephone contact with clients.

5. Provide opportunities for the Counselor Trainee/Intern to engage in the provision of clinical services, namely the diagnosis and treatment of mental disorders. Such services include, but are not limited to, psychological testing, diagnostic assessment, providing appropriate treatment interventions, and developing a comprehensive and individualized treatment plan for each client served. The provision of clinical services must include individual counseling (a minimum of 80 clock hours is required) and co-facilitating group (a minimum of 16 hours is required). Other formats of clinical services include group, couples, and family counseling, determined by the internship site supervisor and the student intern.

6. If a Counselor Trainee/Intern is to engage in off-site services (e.g., home-based counseling, transportation of clients), proper training, safety measures (e.g., use of cell phone, obtaining immunization per Agency policy and at Agency expense, use of Agency vehicle only and only with adequate insurance coverage provided by the Agency), and appropriate supervision will be provided by the Agency. If the Counselor Trainee/Intern will be expected to provide such services, consultation with the Master’s Practicum and Internship Coordinator and/or Internship Instructor will be necessary prior to the commencement of such services.


7. Provide appropriate working conditions and physical arrangements for the Counselor Trainee/Intern, such as desk space for completing paperwork, access to a computer and a telephone, and office space in which to meet with clients privately. In addition, the Agency must provide a clinical instruction environment that is conducive to modeling, demonstration, and training. The clinical instruction environment includes all of the following:

a. settings for individual counseling with assured privacy and sufficient space for appropriate equipment (for example, video monitoring and recording);

b. settings for small-group work with assured privacy and sufficient space for appropriate equipment; c. necessary and appropriate technologies that assist learning, such as audio, video, and telecommunications equipment; d. settings with observational and/or other interactive supervision capabilities; and e. procedures that ensure that the client’s confidentiality and legal rights are protected.

8. Provide the minimum face-to-face supervisory requirements of one (1) hour for every 20 hours of overall service the student provides. Therefore, a 600- hour internship would include a minimum of 30 hours of individual face-to-face supervision, with an additional hour for every 20 hours of internship activity beyond the 600 clock hour minimum. It is strongly recommended that a set day/time for weekly supervision be established.

9. Complete a review of weekly logs and activity reports and complete the Counselor Trainee/Intern evaluation materials in a timely fashion and review these

materials with the Counselor Trainee/Intern.

10. Inform the University of Agency policies and procedures that are relevant to internship assignments and Counselor Trainee/Intern activities.

11. Maintain close communication with the University in relation to internship activities through available means such as internship site supervisor meetings, correspondence with the Master’s Practicum and Internship Coordinator, on-site visits by the Internship Instructor, and telephone contacts.

12. Monitor Counselor Trainee/Intern performance and report to the University Internship Instructor and/or Master’s Practicum and Internship Coordinator any difficulties in performance, ethics, or other internship related activities arise.

13. Allow the Counselor Trainee/Intern to attend weekly internship class sessions (usually held on Mondays, 7:20-10:0 p.m.) for the duration of his/her internship experience (determined by the time period indicated on the first and last pages of this agreement).

Internship Student Responsibilities

1. The student intern will be enrolled in the Clinical Mental Health Counseling Internship course for each semester internship is undertaken (typically 3 credit hours for each of the two semesters internship is undertaken) and will attend in-person all classes/seminars for the Clinical Mental Health Counseling Internship course for the entire length of the agreed upon internship experience (the internship class is usually held on Mondays, 7:20-10:0 p.m.). Internship students will continue working at their internship site (e.g., meeting with clients) until the end of their last semester of internship specified in this agreement, even if they complete the required minimum 600 hours prior to the conclusion of that academic semester.

2. The student intern will complete a weekly log and activity report, obtain his/her internship site supervisor’s initials on each printed activity report, and will

submit the originals on a weekly basis to the Clinical Mental Health Counseling Internship Instructor, and copies to the internship site/clinical supervisor.

3. The student intern will complete duties assigned and at hours scheduled at the internship site, according to the agreement established between the student and agency representative. This includes fulfilling a minimum of 20 clock hours of internship activities per week, reporting directly to the internship site/clinical supervisor regarding client issues during regularly scheduled individual supervision sessions, and meeting with the internship site/clinical supervisor outside of regularly scheduled individual supervision sessions (e.g., in response to client crisis/emergency issues).

4. The student intern will be expected to conduct himself or herself in a professional manner expected of all Counselor Trainees and Professional Counselors throughout the entirety of the internship experience. This means up-holding and abiding by the American Counseling Association's (ACA; 2014) ACA Code of Ethics [http://www.counseling.org], as well as the Code of Ethical Practice and Professional Conduct of the State of Ohio Counselor, Social Worker, and Marriage and Family Therapist Board (Rule 4757-5-01 of the ORC) [http://www.cswmft.ohio.gov].

5. The student intern is responsible for ensuring that all paperwork related to the internship experience is completed in a timely fashion (i.e., according to

deadlines specified in this Manual and in Internship class) and on file.

6. The student intern will be certain the internship site and assigned site/clinical supervisor receive a copy of the University calendar, student handbook, and this Internship Manual.

7. The student intern will be certain that the Internship Site and Master’s Practicum and Internship Coordinator receive copies of the completed Internship

Agreement form and the Assigned Supervisor Qualifications form by July 1st, if starting Fall semester; December 1st, if starting Spring semester; or by May 1st, if starting Summer term. The student will also be certain that the CES mid-internship evaluation form, CES final evaluation form, and the evaluation of the internship (Site and University) are properly completed and placed in the student’s internship file.

8. The student will purchase professional liability insurance and have proof of current coverage available throughout the internship experience.

9. The student will be registered as a “Counselor Trainee” with the Ohio CSW&MFT Board for the entirety of internship.

http://www.counseling.org/



The signatures below indicate that each person understands the Internship requirements for the Clinical Mental Health Counseling Master’s degree Program at Kent State University. The signatures also represent each person’s agreement to uphold his or her respective responsibilities outlined in this Internship Agreement form.

The Clinical Mental Health Counseling Internship will take place (check one):

Fall and Spring (approx. 36 weeks total, including Fall final exam week, 4-week winter break, and Spring break)

Spring and Summer (approx. 31 weeks total, including Spring break, Spring final exam week, 4-week spring/summer intersession, and 10 week summer term)

Summer and Fall (approx. 26 weeks total, including 10-week summer term, one week in-between summer term and start of Fall semester)

Agency Representative Agency Name, Address, and Telephone #:

Signed:

Printed:

Title:

Date: ( )

Student Master’s Practicum and Internship Coordinator

Signed: Signed:

Printed: Printed:

Date: Date:




ASSIGNED SUPERVISOR QUALIFICATIONS FORM

Directions: Please type or print CLEARLY all requested information. This form needs to be completed at or about the time the Internship Agreement Form is completed (i.e., by July 1, if starting Fall semester; December 1, if starting Spring semester; or May 1, if starting Summer term) and the original submitted to the Master’s Practicum and Internship Coordinator.

Name of Clinical Mental Health Counseling Student Intern:

Name, Address, and Phone # (with area code) of assigned Internship Site Supervisor: (or attach business card)

Graduate Degree(s) of Internship Supervisor (include academic institution and date of earning degree(s)):

Certificate(s) and License(s) of Internship Supervisor (include accrediting body and date of expiration):

Internship will extend for hours a week (minimum of 20 hours/week) for weeks, totaling at least 600 clock hours of service, of which a minimum of 240 clock hours are devoted to direct, face-to-face service to clients (80 of which are in individual client contact). Clinical services will include the diagnosis and treatment of mental disorders. Minimum individual face-to-face supervision hours to be provided each week =1 hour of individual supervision for every 20 work hours. It is strongly recommended that a set day/time for weekly individual supervision be established for the entirety of internship. The Internship Site/Clinical Supervisor will assume full and direct legal responsibility for the welfare of all clients seen by the Student Intern.

* Please attach a brochure of the agency/service organization.

Internship Site/Clinical Supervisor’s Signature: Date:

Printed Internship Site/Clinical Supervisor’s Name:

Agency Name:

Student Intern’s Signature: Date:

Printed Student Intern’s Name:

Master’s Practicum & Internship Coordinator’s Signature: Date:


REPORTING WEEKLY INTERN ACTIVITY REPORT & LOG

I. Weekly Internship Activity Log: A copy of the CMHC Internship Log can be downloaded at http://www.kent.edu/ehhs/ldes/ces/documents Students are required to turn in their completed logs (with signatures) weekly to their internship instructor. The Weekly Activity Report (see below) should be attached to each log.

II. WEEKLY ACTIVITY REPORT: A copy of the Weekly Activity Report can be downloaded at http://www.kent.edu/ehhs/ldes/ces/documents Students are required to turn in a completed Activity Report (with signatures) with each log. The report will ask student to describe their weekly assignment within the agency and any concerns they may have about internship.

http://www.kent.edu/ehhs/ldes/ces/documents

http://www.kent.edu/ehhs/ldes/ces/documents


Student Name: Banner ID:

Person Completing Evaluation: Title:

Instructions: Clearly write your score in the far right column titled “Score”. Place and “X” in the “Score” column if the standard was not observed.

When this form is completed, turn it into the CES secretary for data entry. Items scored as 4 -5 are considered acceptable. If any items are scored as 1 or 2, the instructor should discuss specific concerns with the student and

ways the student can improve.

Standard 1 2 3 4 5 Score

1.D. Self-care strategies appropriate to the counselor role

The student cannot verbalize a need for self-care

The student cannot verbalize strategies for self-care

The student can verbalize self-care strategies but does not or cannot implement the strategies

The student integrates self-care strategies but not continually

The student continually integrates and adapts new self- care strategies

5.B. Counselor characteristics and behaviors that influence helping processes

5.b.1. Empathy

The verbal and behavioral expression by the student does not attend to and detract significantly from the client

When the student responds they do so in such a way that it subtracts noticeable affect from the communications of the client

The expressions of the student are essentially interchangeable with those of the client in that they express the same affect and meaning

The responses of the student add noticeably to the client in such a way to express feeling levels deeper then those expressed by the client

The student’s responses add significantly to the feeling and meaning of the client expression and when the client is in ongoing deep self- exploration, the student remains immediate to that experience

5.b.2. Unconditional Positive Regard

Does not show ANY ability to suspend judgmental thinking, value clients as individuals, and think positively about them

Shows one of three of the following qualities; suspend judgmental thinking, value clients as individuals, and think positively about them

Shows two of three of the following qualities; suspend judgmental thinking, value clients as individuals, and think positively about them

Shows three of the following qualities (but not consistently across clients); suspend judgmental thinking, value clients as individuals, and think positively about them

Student is ABLE to show consistently across clients the ability to suspend judgmental thinking, value clients as individuals, and think positively about them

5.b.3. Congruence

Is incongruent among, self, thoughts, and actions

Is aware of incongruence among self, thoughts, and actions

Begins to take action in client sessions to be more congruent in their experience of the client

Takes regular action in client sessions to be more congruent in their experience of the client

Demonstrates consistent congruence among self, thoughts, and actions

5.C. Essential interviewing and counseling skills

5.c.1. Establishing Relationships

Shows no pattern for establishing a counseling relationship

Starts counseling relationship with introduction but w/o structured ethical introduction (professional disclosure, fees, cancellation, orientation, confidentiality, informed consent, questions)

Starts counseling relationship with introduction but misses many components of a structured ethical introduction (professional disclosure, fees, cancellation, orientation, confidentiality, informed consent, questions)

Starts counseling relationship with introduction but misses a few components of a structured ethical introduction (professional disclosure, fees, cancellation, orientation, confidentiality, informed consent, questions)

Demonstrates a complete process of establishing a counseling relationship with a complete ethical introduction (professional disclosure, fees, cancellation, orientation, confidentiality, informed consent, questions)

CMHC Internship Skill Evaluation Form



5.c.2. Attending Does not practice Shows some Attending behavior is Attending behavior is Attending behavior is attending behavior inaccurate and accurate but mostly consistent and accurate and

inconsistent attending inconsistent; visual accurate; visual complete

behaviors; visual contact, verbal contact, verbal contact, verbal tracking, vocal tracking, vocal tracking, vocal qualities, body qualities, body qualities, body language language language

5.c.3. Questions Asks few questions or Uses unintentional Selects open and Selects open and Include questions the questions do not pattern of questions closed ended closed ended appropriately; using

appear to follow any and does not follow questions questions closed and open

logical pattern; does logical pattern of appropriately; does appropriately and ended questions and

not verbally track client verbal tracking not follow client mostly tracks client closely follows verbal

client verbal tracking tracking

5.c.4. Observation Makes no use of Demonstrates some Uses observation Uses appropriate Uses appropriate Skills observation skills observational skills skills but rarely uses observation skills with observation skills and

but does not show immediacy in occasional immediacy is able to show

immediacy in presenting them to immediacy with them

response to the client the client when working with a

client

5.c.5. Encouraging Makes no use of Rarely uses Uses primarily non- Uses a range of Intentionally uses a encouraging skills encouraging verbal or minimal encouragers (head range of

comments to client encouragers with nods, uh-huh, appropriate/timely

client keywords, and short encouraging skills

statements with with a client

client) 5.c.6. Paraphrasing Paraphrases w/o Paraphrases and Paraphrases getting Paraphrases w/ Paraphrases using

intentionally using misses key points in key verbal tracking check-out but lacks sentence stem,

any of the four client verbal tracking but missing check-out full breath of the keywords, essence,

dimensions; sentence and components of and use of key words client story and check-out

stem, keywords, the four dimensions essence, and check- out

5.c.7. Summarizing Summarizes w/o Summarizes and Summarizes getting Summarizes w/ check- Summarizes using intentionally using misses key points in key verbal tracking out but lacks full sentence stem,

any of the four client verbal tracking but missing check-out breath of the client keywords, essence,

dimensions; sentence and components of and use of key words story and check-out

stem, keywords, the four dimensions essence, and check- out

5.c.8. Ending a Makes no use of skills Summarizes end of Summarizes end of Summarizes w/ Does complete Session to end a session session; there is little session; includes checkout, may miss summary, check-out,

process other than to check-out with client. one of the following strengths, and

explain parts of what student may or may components; client continuity plan with

happened in the not assign homework strengths and client as part of

session; student but w/o client continuity plan for summary

assigns homework involvement next session. May or w/o client may not assign involvement homework and does so with client involvement

5.c.9. Reflection of Does not reflect Attempts to reflect Reflects feelings Consistently reflects Consistently reflects Feelings feelings feelings but does so inconsistently with feelings appropriately feelings appropriately

inaccurately varying levels of and integrates it into

appropriateness case

conceptualization



B.1. Demonstrates the ability to apply and adhere to ethical and legal standards in clinical mental health counseling.

B.1.a. Confidentiality Inappropriately reveals private information to select others

Always maintains appropriate confidentiality

B.1.b. Boundaries Has serious boundary problems with clients

Has minor boundary problems with clients

Has no boundary problems with clients

B.1.c. Record Keeping Appropriate records are not kept

Records are kept infrequently, inaccurately and sloppily

Records are kept well except for lapses in two areas (e.g., timely and neatly)

Records are kept well except for lapses in one area (e.g., timely and neatly)

Records are kept accurately and neatly at all times.

B.1.d. Areas of Competence

Consistently counsels clients outside many areas of expected developmental level

Often counsels clients outside many areas of expected developmental level

Sometimes counsels clients outside a few areas of expected developmental level

Rarely counsels clients outside any areas of expected developmental level

Never counsels clients outside any areas of expected developmental level

B.1.e. Counseling Minors

Always disregards client development and fails to inform care givers appropriately

Often disregards client development and fails to inform care givers appropriately

Sometimes disregards client development or fails to inform care givers appropriately

Rarely disregards client development or fails to inform care givers appropriately

Never disregards client development or fails to inform care givers appropriately

D.1. Uses the principles and practices of dx, tx, referral, and prevention of mental and emotional disorders to initiate, maintain, and terminate counseling.

D.1.a. Appropriately uses the principles and practices of diagnosis to initiate counseling

Never Rarely Sometimes Always Always and can integrate into treatment planning

D.1.b. Appropriately uses the principles and practices of diagnosis to maintain counseling


D.1.c. Appropriately uses the principles and practices of diagnosis to terminate counseling


D.1.d. Appropriately uses the principles and practices of treatment to initiate counseling


D.1.e. Appropriately uses the principles and practices of treatment to maintain counseling


D.1.f. Appropriately uses the principles and practices of treatment to terminate counseling


D.1.g. Appropriately uses the principles and practices of referring to initiate counseling


D.1.h. Appropriately uses the principles and practices of referring to maintain counseling




D.1.i. Appropriately uses the principles and practices of referring to terminate counseling


D.1.j. Appropriately uses the principles and practices of prevention to initiate counseling


D.1.k. Appropriately uses the principles and practices of prevention to maintain counseling


D.1.l. Appropriately uses the principles and practices of prevention to terminate counseling


D.2. Applies multicultural competencies to clinical mental health counseling involving case conceptualization, diagnosis, treatment, referral, and prevention of mental and emotional disorders.

Never Rarely Sometimes Often Always

D.3. Promotes optimal human development, wellness, and mental health through prevention, education, and advocacy activities.


D.4. Applies effective strategies to promote client understanding of and access to a variety of community resources.

Does not use nor understand strategies

Rarely uses or often misuses strategies

Sometimes uses or sometimes misuses strategies

Usually uses strategies appropriately

Always uses strategies appropriately

D.5. Demonstrates appropriate use of culturally responsive individual, couple, family, group, and systems modalities for initiating, maintaining, and terminating counseling.

D.5.a. Demonstrates appropriate use of culturally responsive individual modalities


D.5.b. Demonstrates appropriate use of culturally responsive couple modalities


D.5.c. Demonstrates appropriate use of culturally responsive family modalities


D.5.d. Demonstrates appropriate use of culturally responsive group modalities




D.5.e. Demonstrates appropriate use of culturally responsive systems modalities


D.6. Demonstrates the ability to use procedures for assessing and managing suicide risk.

Does not recognize signs of suicide

Recognizes signs of suicide but does not or does not adequately assess or manages risk but seeks supervision

Assess or manages suicide risk in a basic or shallow manner

Provides a thorough/comprehen sive assessment of suicide risk; comprehensively manages suicide risk with short and long term goals for treatment – though is apprehensive and/or needs great amounts of supervision

Provides a thorough/comprehen sive assessment of suicide risk; comprehensively manages suicide risk with short and long term goals for treatment

D.7. Applies current record-keeping standards related to clinical mental heal counseling

D.7.a. Timely in accordance to site guidelines


D.7.b. Record Security Never Rarely Sometimes Often Always D.7.c. Accuracy Never Rarely Sometimes Often Always D.7.d. Thoroughness Never Rarely Sometimes Often Always D.7.e. Conciseness Never Rarely Sometimes Often Always D.7.f. Makes documented links to treatment plan


D.8. Provides appropriate counseling strategies when working with clients with addiction and co- occurring disorders.


D.9. Demonstrates the ability to recognize his or her own limitations as a clinical mental health counselor and to seek supervision or refer clients when appropriate.

D.9.a. Recognition of Limitations


D.9.b. Seeks supervision when necessary


D.9.c. Makes Appropriate Referrals


F.1. Maintains information regarding community resources to make appropriate referrals.

Never make referrals Does not recognize when referrals are needed, but makes them after prompting

Usually recognizes the need for referrals and makes them after prompting

Usually recognizes the need for referrals and makes them appropriately

Always recognizes the need for referrals and makes them appropriately

H.2. Demonstrates skill in conducting an intake interview, a mental status evaluation, a biopsychosocial history, a mental health history, and a psychological assessment for treatment planning and caseload management.



H.2.a. Skill in conducting an intake interview

Does not understand how to conduct, interpret, or integrate an intake with treatment

Has basic knowledge of how to conduct an intake but has difficulty in the skill of conducting an intake

Has basic knowledge and skill if effectively conducting an intake

Can effectively conduct an intake and has a basic knowledge of how to conceptualize the intake into treatment

Can effectively conduct an intake, utilize information from the intake into ongoing diagnosis and treatment planning

H.2.b. Skill in conducting a mental status evaluation

Does not understand how to conduct, interpret, or integrate a MSE with treatment

Has basic knowledge of how to conduct a MSE but has difficulty in the skill of conducting a the MSE

Has basic knowledge and skill if effectively conducting an MSE

Can effectively conduct an MSE and has a basic knowledge of how to conceptualize the results of the MSE into treatment

Can effectively conduct a MSE, utilize information from the MSE into ongoing diagnosis and treatment planning

H.2.c. Skill in conducting a biopsychosocial history

Does not understand how to conduct, interpret, or integrate a BPS Hx with treatment

Has basic knowledge of how to conduct a BPS Hx but has difficulty in the skill of conducting a the BPS Hx

Has basic knowledge and skill if effectively conducting an BPS Hx

Can effectively conduct an BPS Hx and has a basic knowledge of how to conceptualize the results of the BPS Hx into treatment

Can effectively conduct a BPS Hx, utilize information from the BPS Hx into ongoing diagnosis and treatment planning

H.2.d. Skill in conducting a mental health history

Does not understand how to conduct, interpret, or integrate a MH Hx with treatment

Has basic knowledge of how to conduct a MH Hx but has difficulty in the skill of conducting a the MH Hx

Has basic knowledge and skill if effectively conducting an MH Hx

Can effectively conduct an MH Hx and has a basic knowledge of how to conceptualize the results of the MH Hx into treatment

Can effectively conduct a BPS Hx, utilize information from the MH Hx into ongoing diagnosis and treatment planning

H.2.e. Skill in conducting psychological assessment(s)

Does not understand how to conduct, interpret, or integrate a psychological assessment with treatment

Has basic knowledge of how to select, administer, score, and use a psychological assessment in treatment along with integrating results into treatment

Can effectively select, administer, score, and use a psychological assessment in treatment along with integrating results into treatment with extensive supervision

Can effectively select, administer, score, and use a psychological assessment in treatment along with integrating results into treatment with minimal supervision

Can effectively select, administer, score, and use a psychological assessment in treatment along with integrating results into treatment independently

H.3. Screens for addiction, aggression, and danger to self and/or others, as well as co-occurring mental disorders.

H.3.a. Appropriately Screens for Addiction


H.3.b. Appropriately Screens for Aggression


H.3.c. Appropriately Screens for Danger to Self


H.3.d. Appropriately Screens for Danger to Others


H.3.e. Appropriately Screens for Co- Occurring Disorders


J.1. Applies relevant research findings to inform the practice of clinical mental health counseling.

Does not participate in this activity

Looks at research but does not understand it

Looks at research and tries to use it with clients though needs extensive assistance

Uses research to work with clients with minimal assistance

Uses research to work with clients independently



L.1. Demonstrates appropriate use of diagnostic tools, including the current edition of the DSM, to describe the symptoms and clinical presentation of clients with mental and emotional impairments.


L.2. Is able to conceptualize an accurate multi-axial diagnosis of disorders presented by a client and discuss the differential diagnosis with collaborating professionals.


CES 1. Ability to structure a session intentionally


CES 2. Integrates multiple micro-skills fluidly


Provide 3-4 specific recommendations for continued professional growth and development in the space below (or attach a separate sheet):

For Site Supervisors completing evaluation on Internship I students (Check One):

Based on the above standards, this student has met the skills requirement for an Internship I student. Based on the above standards, this student has not met the skills requirement for an Internship I student.

For Site Supervisors completing evaluation on Internship II students (Check One):

Based on the above standards, this student has met the skills requirement for an Internship II student. Based on the above standards, this student has not met the skills requirement for an Internship II student.


Site Supervisor’s Signature: Date:





Instructions:

This form is to be completed at the end of Internship I and Internship II.

When this form is completed, turn it into the CES secretary for data entry.

Please place a check in the appropriate box. Professional behavior is expected of all CES students during class, while working in the Counseling and Human Development Center, and while

working with other students on class assignments. If a students professional behavior is deemed as questionable, programmatic remediation may need to occur. If any item is marked as 1-3, please inform the CES Master’s Programs Coordinator (Dr. Guillot-Miller) and remediation will be determined. In Section B, if any of the Professional Behaviors are not “always” done (meaning NEVER not done), please inform the CES Master’s Programs Coordinator (Dr. Guillot-Miller) and remediation will be determined. However, there are multiple levels of severity of professional behavior and remediation could occur even if there was only once correction.

All scores contribute to the overall grade in this course.

Section A: Professional Behavior Never Occurs After Multiple Corrections

Occurs After Multiple

Corrections

Occurs After Few

Corrections

Occurs After One Correction

Always occurs

Not Applicable

1 2 3 4 5 X Dresses Appropriately Is on time for appointments Is on time to site Interacts with colleagues in a professional manner Interacts with office staff in a professional manner Has professional demeanor on telephone with clients/parents

Completes record keeping in a timely manner Treats clients with respect in waiting areas Arrives at site on agreed dates and times Calls to report inability to come to site in a timely and professional manner

Arrives prepared for supervision Assists colleagues when appropriate and needed Follows site guidelines / policies Accepts feedback Arrives prepared for client sessions Takes initiative on projects when appropriate Maintains proper personal hygiene

Section B: Professional Behavior Serious Concern Always

Discusses client cases only in appropriate settings Maintains client confidentiality through proper record handling Is respectful of all clients regardless of any differences Complies with supervisor directions Seeks supervision when needed

For Site Supervisors completing evaluation on Internship I students (Check One): Based on the above standards, this student has met the skills requirement for an Internship I student. Based on the above standards, this student has not met the skills requirement for an Internship I student.

For Site Supervisors completing evaluation on Internship II students (Check One):

Based on the above standards, this student has met the skills requirement for an Internship II student. Based on the above standards, this student has not met the skills requirement for an Internship II student.

Student Signature: Date:

Site Supervisor’s Signature: Date:


Content in this evaluation taken from Ivey & Ivey (2008); Carkhuff, (1972); and Stoltenberg, McNeill, & Delworth (1998).

CMHC Internship Professional

Behavior Evaluation Form




This evaluation is for the purpose of providing feedback to the Site/Clinical Supervisor, the Agency, and the University regarding student perceptions of the internship experience. This instrument is designed as a guide to facilitate the sharing of the most significant perceptions and impressions that occur throughout the internship experience. As a student counselor and a beginning professional, you are urged to complete this instrument completely and honestly. You should already have begun this kind of critical sharing with your site/clinical supervisor, others in the Agency, and your faculty Internship Instructor. Your responses can aid your own professional development, and your assessment will significantly help the Agency and the University be even more responsive to student needs.

1. Complete the rating form as follows (circle appropriate responses for each item):

5 -- Indicates complete satisfaction or an extremely positive response with the item. Where

behavior is referred to, the behavior was always present when appropriate. 4 -- Moderate satisfaction: Desired behavior or condition was frequently present. 3 -- Somewhat satisfied: Desired behavior or condition was sometimes absent. 2 -- Somewhat dissatisfied: Desired behavior or condition was often absent. 1 -- Extremely dissatisfied: Desired behavior or condition was seldom present. X -- It is not possible to assess this item.

2. Provide written comments regarding those items for which you have a special concern.

I. The Internship Process

1 Was there sufficient information about the internship prior to actually starting the experience? 5 4 3 2 1 X

2 Did you feel the kind of setting provided was appropriate to your needs and interests? 5 4 3 2 1 X

3 Was orientation at the agency sufficient when the internship began? 5 4 3 2 1 X

4 Overall, did the internship instructor meet his/her responsibilities for your internship experience? 5 4 3 2 1 X

5 During the internship experience, did you feel that you were treated as an individual with respect for your own special circumstances?

5 4 3 2 1 X

6 Was the agency adequately prepared for your arrival? 5 4 3 2 1 X

II. The Agency Setting

1 Was interaction with other counselors and related disciplines sufficient? 5 4 3 2 1 X

2 Did the agency provide you with adequate working conditions? 5 4 3 2 1 X

3 Overall, did you feel the agency attached sufficient importance to your internship experience? 5 4 3 2 1 X

III. Professional Development

1 Did the experience acquaint you with the operation of a community service agency? 5 4 3 2 1 X

2 Did the internship experience improve your capacity to work with people in a helping relationship? 5 4 3 2 1 X

3 Did the placement acquaint you with resources available in the community? 5 4 3 2 1 X

4 Did the internship significantly increase your knowledge of specific problems in the community, e.g., poverty, mental illness, aging, alcoholism and other addictions, and so on?

5 4 3 2 1 X

5 Rate your general level of satisfaction with the amount and kind of clinical practice activity you were assigned. 5 4 3 2 1 X

6 Was there a sufficient diversity of learning activities? 5 4 3 2 1 X

7 Were there opportunities to be part of the “larger agency” such as by attending staff meetings, in-service training, and so on?

5 4 3 2 1 X

8 Did this agency experience help you understand and use professional record keeping procedures? 5 4 3 2 1 X

(continue to next page)

CMHC Internship Professional

Assessment of the Clinical Experience


IV. Direct Supervision

1 Did your supervisor stimulate professional counselor identity? 5 4 3 2 1 X

2 Did your supervisor help you feel accepted and respected as a person? 5 4 3 2 1 X

3 Did your supervisor help in demonstrating professional relationships with staff members at the site? 5 4 3 2 1 X

4 Did your supervisor meet with you for supervision at established times and for the agreed upon time? 5 4 3 2 1 X

5 Did your supervisor assist in conceptualizing your clients? 5 4 3 2 1 X

6 Did your supervisor help clarify objectives for your counseling sessions? 5 4 3 2 1 X

7 Did your supervisor help organize relevant case data in planning procedures for working with your clients? 5 4 3 2 1 X

8 Did your supervisor guide you in generating your own solutions to problems faced with clients? 5 4 3 2 1 X

9 Did your supervisor provide you with useful feedback regarding your counseling skills? 5 4 3 2 1 X

10 Did your supervisor help you focus on how your personal style influenced clients? 5 4 3 2 1 X

11 Did your supervisor adequately reinforce the development of your strengths and capabilities? 5 4 3 2 1 X

12 Did your supervisor help you use appraisal instruments constructively in counseling? 5 4 3 2 1 X

13 Was your supervisor helpful in critiquing your report writing? 5 4 3 2 1 X

14 Did your supervisor allow and encourage you to evaluate your work with clients? 5 4 3 2 1 X

Optional: Provide additional comments in the space below (or attach a separate sheet):

The Site/Clinical Supervisor and Intern have been involved in an evaluation process that they have discussed with one another. Significant disagreement on the part of the Intern or Site/Clinical Supervisor regarding this assessment should be noted in writing and forwarded to the Internship Instructor as an addendum to this form.


Evaluator’s Signature: Date:

Instructor’s Signature: Date:



CMHC Internship Completion Form

The following signatures indicate that______________________________________ satisfactorily fulfilled the expectations of the (Name of Student Intern) Internship experience and met all requirements of the Clinical Mental Health Counseling Master’s degree Internship.

Site Name and Address: ________________________________________________________________________________________

Internship I Internship II Total

1. Individual Client Contact Hours

2. Group Client Contact Hours

3. Couple/Family Contact Hours

4. Other Contact Hours

5. Total # of Direct Service Hours (Line 1 + Line 2 + Line 3 + Line 4)

6. Individual Supervision Hours

7. Group Supervision Hours (On-Site Supervision)

8. Total # of Supervision Hours from Log (Line 6 + Line 7)

9. All Non-direct Hours (EXCLUDING Supervision Hours)

10. Total # of Non-direct Hours (Line 8 + Line 9)

11. Total # of Direct and Non-Direct Service Hours (Line 5 + 10)

12. Total Hours of Group Supervision from Group Supervision/Class Attendance Log

13. Total Hours of Class Instruction from Group Supervision/Class Attendance Log

14. Total Hours of Supervision (Line 8 + 22)

15. Total (Line 11 + Line 12 + Line 13)

Internship I

____________________________________ ______________________________________ _____________________ Student Name (Print) Student’s Signature Date

____________________________________ ______________________________________ _____________________ Site Supervisor Name (Print) Site Supervisor’s Signature Date

____________________________________ ______________________________________ _____________________ Internship I Instructor Name (Print) Internship I Instructor’s Signature Date Internship II

____________________________________ ______________________________________ _____________________ Student Name (Print) Student’s Signature Date

____________________________________ ______________________________________ _____________________ Site Supervisor Name (Print) Site Supervisor’s Signature Date

____________________________________ _______________________________________ _____________________ Internship II Instructor Name (Print) Internship II Instructor’s Signature Date ______________________________________________________________________ _____________________ Master’s Practicum and Internship Coordinator Signature Date