This form allows students to document their experience in therapy and other psychological interventions. Thus, while this form
lists a wide range of experiences that one might have had, no one will have all these experiences, either in one semester or
even at the end of training. In short, each student will have many blank areas on the form. **If you completed your internship
hours at more than one site please complete one form for each site.
Also, please note that Items 1 - 3 below are meant to be mutually exclusive; thus, any internship hour should not be counted
more than once across these items. You may have some experiences that could potentially fall under more than one category,
but it is your responsibility to select the category that best captures your experiences.
STUDENT NAME:_________________________ STUDENT #:_______________________ SEMESTERS/YEAR: ________________
INTERNSHIP I COURSE INSTRUCTOR:________________________________________________________
INTERNSHIP II COURSE INSTRUCTOR:________________________________________________________
SITE SUPERVISOR NAME:______________________ ACADEMIC ADVISOR NAME:_____________________
NAME OF INTERNSHIP SITE:_____________________________________
Circle Setting Type: Community Mental Health Center; Correctional Setting; Inpatient Hospital; Military; Outpatient
Medical/Psychiatric Clinic and Hospital; University Counseling Center; School Setting, Other (specify:________)
1. DIRECT COUNSELING EXPERIENCE- In this section, record actual clock hours in direct service to clients/patients. Hours should
not be counted in more than one category. Time spent gathering information about the client/patient, but not in the actual
presence of the client/patient, should be recorded under Support Activities below. Record the total numbers of hours of each
activity in the space provided. Count each hour of a group, family, or couples session as one practicum hour. For example, a
two-hour group session with 12 adults is counted as two hours.
Total # of hours
a. Individual Counseling ________
b. Group Counseling (minimum of 10 hours required) ________
c. Couples/Family Counseling ________
2. INDIRECT COUNSELING EXPERIENCE - Record time spent outside the counseling/therapy hour focused on the client/patient
(e.g., chart review, writing process notes, consulting with other professionals about cases, video/audio tape review, planning
interventions, assessment interpretation and report writing). In addition, it includes the hours spent in your practicum site in
didactic training, such as attending seminars:
3. SUPERVISION EXPERIENCE - Supervision is divided into individual and group supervision. Item 3a: Hours are defined as
regularly scheduled, face-to-face individual supervision with specific intent of overseeing the counseling services rendered by
the student. Item 3b: The hours recorded in the group supervision category should reflect the time from your Internship Class.
a. Individual Supervision Hours _______
b. Group Supervision Hours _______
4. TOTAL HOURS AQUIRED THROUGH INTERNSHIP I & INTERNSHIP II (Direct Counseling Experience + Indirect Counseling
Experience + Supervision Experience)
TOTAL HOURS: _______
SIGNATURES OF PRACTICUM INSTRUCTOR: ________________________________(DATE)_________
SIGNATURE OF SITE SUPERVISOR: ________________________________(DATE)_________
SIGNATURE OF STUDENT: ________________________________(DATE)_________
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