![Page 1: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/1.jpg)
Week 1
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
WEEKLY INTERNSHIP LOG
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Activity Total Week Total to Date
Name: _____________________________________ Week of:________________________ (month/day/year)
![Page 2: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/2.jpg)
Week 2
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Total Week Total to DateActivity
![Page 3: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/3.jpg)
Week 3
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 4: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/4.jpg)
Week 4
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 5: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/5.jpg)
Week 5
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 6: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/6.jpg)
Week 6
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 7: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/7.jpg)
Week 7
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 8: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/8.jpg)
Week 8
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 9: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/9.jpg)
Week 9
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 10: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/10.jpg)
Week 10
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 11: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/11.jpg)
Week 11
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 12: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/12.jpg)
Week 12
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 13: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/13.jpg)
Week 13
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 14: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/14.jpg)
Week 14
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 15: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/15.jpg)
Week 15
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 16: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/16.jpg)
Week 16
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 17: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/17.jpg)
Week 17
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 18: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/18.jpg)
Week 18
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 19: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/19.jpg)
Week 19
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 20: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/20.jpg)
Week 20
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 21: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/21.jpg)
Week 21
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 22: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/22.jpg)
Week 22
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 23: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/23.jpg)
Week 23
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 24: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/24.jpg)
Week 24
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 25: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/25.jpg)
Week 25
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 26: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/26.jpg)
Week 26
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 27: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/27.jpg)
Week 27
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 28: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/28.jpg)
Week 28
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 29: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/29.jpg)
Week 29
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 30: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/30.jpg)
Week 30
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 31: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/31.jpg)
Week 31
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 32: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/32.jpg)
Week 32
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 33: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/33.jpg)
Week 33
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 34: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/34.jpg)
Week 34
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 35: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/35.jpg)
Week 35
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 36: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/36.jpg)
Week 36
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 37: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/37.jpg)
Week 37
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 38: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/38.jpg)
Week 38
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 39: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/39.jpg)
Week 39
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 40: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/40.jpg)
Week 40
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 41: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/41.jpg)
Week 41
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 42: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/42.jpg)
Week 42
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 43: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/43.jpg)
Week 43
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 44: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/44.jpg)
Week 44
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 45: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/45.jpg)
Week 45
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 46: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/46.jpg)
Week 46
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 47: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/47.jpg)
Week 47
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 48: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/48.jpg)
Week 48
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 49: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/49.jpg)
Week 49
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 50: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/50.jpg)
Week 50
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
![Page 51: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/51.jpg)
Week 51
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
![Page 52: Week 1 · Week 1 Agency Name:_____ Site Supervisor:_____ ... Non-Direct Service On-Site Supervision Individual supervision hours (minimum 1 hour for 20 worked) 0 Group supervision](https://reader034.vdocuments.net/reader034/viewer/2022042420/5f380e92c55eed25202e5a0e/html5/thumbnails/52.jpg)
Week 52
Name: _____________________________________ Week of:________________________ (month/day/year)
Agency Name:_______________________________ Site Supervisor:___________________________
Individual client contact hours 0
Group client contact hours 0
Couple/family client contact hours 0
*Other (describe below) 0
Total Direct Service 0 0
Non-Direct Service
On-Site Supervision
Individual supervision hours (minimum 1 hour for 20 worked) 0
Group supervision hours (on-site) 0
Internship class (2.5 hours) 0
Subtotal for Supervision 0 0
Staff meetings 0
In-service training, workshop attendance 0
Documentation 0
Contact with related agencies 0
**Other (describe below) 0
Total Non-Direct Service 0 0
GRAND TOTALS 0 0
Internship Instructor Signature: ________________________________________ Date __________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Directions: This log, along with the 2-page activity report, should be completed weekly, reviewed with and signed by the
on-site internship supervisor, and turned in to the internship instructor to be placed in the student's internship file. Please
staple all three pages prior to submission.
Activity Total Week Total to Date
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CES 67792 & 67892: CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP I & II
WEEKLY INTERNSHIP LOG