Post on 10-Jul-2020
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)
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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