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(individual, family, couple, and group counseling) (Mississippi)

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Supervision Reporting Log
Face to Face
(individual, family, couple, and group counseling)
and Other Services
Supervisee:
Supervisor:
Site of Clinical Hours:
Direct Clinical Hours include: Face to Face With Client (individual, family, couple, and group counseling)
Report in Hours e.g. 1, 2, 3.75, etc.
Supervisee’s Signature____________________________________ Date:________________________________
6XSHUYLVRU¶V6LJQDWXUHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB'DWHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
Supervision
Total
hours
(of supervised clinical
practice – not more
than 40/week)
WEEK
(MM/DD-DD/YY)
Face to Face Counseling
Other
Services
Individual
Supervision
Hours
(with Supervisor)
Group
Supervision
Hours
(with Supervisor)
Individual
Couples/
Family
Group
Testing/
Assess
Total
Hours
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
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(individual, family, couple, and group counseling) (Mississippi)

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Completed 31 May 2022

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