CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP MANUAL · 2015-04-28 · in Clinical Mental Health...

Revised April 2015 of 23

College of Education, Health, & Human Services

Counselor Education and Supervision (CES) Program

CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP MANUAL

TABLE OF CONTENTS

Item Page Deadline

Internship Planning Process 2-3 June 15 (if starting in Fall semester)

November 15 (if starting in Spring semester)

April 15 (if starting in Summer term)

Internship Eligibility Form 4

Internship Agreement 5-8

Assigned Supervisor Qualifications Form 9

Reporting: Weekly Internship Log and Activity Report 10-12 Due weekly in internship class / seminar

CMHC Internship Skill Evaluation Form 13-22 Due at the end of Internship I and Internship II

CMHC Internship Professional Behavior Evaluation Form

20 Due at the end of Internship I and Internship II

Interns Assessment of the Internship 21-22 Due at end of internship

Internship Completion Form 23 Due at end of internship

For information contact:

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

OR Dr. Steve Rainey

Master’s Practicum and Internship Coordinator

310 White Hall, College of Education, Kent State University, Kent, OH 44242 (330) 672-2662 * * * * FAX (330) 672-2472

KENT STATE UNIVERSITY


CLINICAL MENTAL HEALTH COUNSELING PROGRAM INTERNSHIP IN CLINICAL MENTAL HEALTH COUNSELING

INTERNSHIP PLANNING PROCESS

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

Internship is undertaken at the conclusion of the student’s program, with no more than 6 credit hours remaining to complete the 60-credit hour master’s degree in Clinical Mental Health Counseling (excluding the 6 credit hours required for internship). The internship is undertaken over two semesters (or one semester and one summer term) and therefore students will be enrolled for 3 credit hours of internship for each of the two semesters of their internship experience. Students will not be able to undertake their entire internship in one semester and therefore will not be enrolled for 6 credit hours of internship in one semester.

The CES Faculty have determined that all CACREP core area courses (as listed on the Clinical Mental Health Counseling prospectus) need to be completed prior to the start of internship. Four additional courses are also prerequisites to internship: _____ CES 6/77628: Diagnosis in Counseling _____ CES 6/78130: Psychopathology for Counselors _____ CES 6/77492: Practicum I _____ CES 6/77592: Practicum II

Successful completion of all CACREP core area courses and the four courses listed above needs to be verified on the student’s academic transcript. It is important that each student identifies and selects an internship setting that suits his or her learning requirements. In order to accomplish this, considerable planning and careful preparation must be completed before the student actually begins the internship experience. The internship experience must provide the student with opportunities to engage in clinical counseling services; that is, the student must engage in the diagnosis and treatment of mental disorders, under the supervision of a licensed Professional Clinical Counselor (PCC) who has the supervisory endorsement of the Ohio CSW&MFT Board (PCC-S credential). Clinical services provided during internship include, but are not limited to, screening clients for treatment eligibility, conducting comprehensive assessments, determining DSM diagnoses, providing appropriate treatment interventions to clients, and constructing individualized treatment plans. The clinical nature of the internship experience fulfills licensure eligibility requirements in the state of Ohio. The Clinical Mental Health Counseling internship experience must therefore be undertaken and completed in Ohio. Once a potential internship site has been located by a student, the Master’s Practicum and Internship Coordinator will need to verify the appropriateness of the setting and supervision prior to the student beginning his or her internship experience (this usually entails telephone contact with the proposed site supervisor or appropriate representative of the proposed internship site). What follows is a step-by-step process for students to follow in identifying and securing an internship setting and experience. As a student, it is your responsibility to begin the process early (i.e., at least one full semester prior to the beginning of the internship experience). This means completing the Internship Eligibility Form and meeting with your CES faculty advisor to review and sign it. Your careful attention to the Internship Eligibility Form will ensure that the internship location process begins smoothly and will help ensure that you identify an appropriate setting. If you have questions about completing the internship materials, contact your CES faculty advisor or the Master’s Practicum and Internship Coordinator. Step-by-Step Directions 1. Complete Internship Eligibility Form: The first step of the internship application process is completing the Internship Eligibility Form, found within this

Internship Manual, with the three (3) necessary accompanying materials: (a) current academic transcript, (b) Student Profile, and (c) Professional Liability Insurance Policy. Your completion of this form will help to clarify your needs and goals for the internship experience and will help identify an appropriate internship placement. You will need to have completed the Internship Eligibility Form (and the three necessary accompanying materials) before meeting with your CES faculty advisor. His or her signature on the form indicates that you are academically ready to begin the internship experience at the start of the semester (or summer term) you have indicated.

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

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

3. Submit Completed Internship Eligibility Form to Master’s Practicum & Internship Coordinator: A copy of the Internship Eligibility Form, signed and dated

by both you and your CES faculty advisor, along with the three necessary accompanying materials (i.e., current academic transcript, Student Profile, and Professional Liability Insurance Policy), are due to the Master’s Practicum and Internship Coordinator by June 15, if starting Fall semester; November 15, if starting Spring semester; or April 15, if starting in the Summer term.

4. Obtain List of Potential Internship Sites in Ohio: A list of potential internship sites in Ohio (primarily Northeast Ohio) is available in the CES office, 310

White Hall. It is the student’s responsibility to contact and secure an internship site and the site must be in Ohio. Your CES faculty advisor and the Master’s Practicum and Internship Coordinator can assist in identifying and recommending particular sites. However, it will be your responsibility to initiate contact


with potential internship sites, schedule interviews, and finalize the internship agreement. 5. Contact Potential Internship Sites: Once you have identified several potential internship sites in Ohio (as a result of conferring with your CES academic

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

6. Interview Guidelines: Once an interview has been scheduled, arrive on time for the scheduled interview. Do not be a “no show”! Remember, you are

representing the Clinical Mental Health Counseling program at KSU. Take with you to the interview a copy of your current resume and a copy of this Clinical Mental Health Counseling Internship Manual to leave with the person with whom you will be interviewing. Provide that person with the name and telephone number of the Master’s Practicum and Internship Coordinator. Clarify that individual and face-to-face weekly supervision will need to be provided by a licensed Professional Clinical Counselor (PCC-S) who has the supervisory endorsement of the Ohio CSW&MFT Board, and who is an employee (part-time, full-time, or contracted with the agency) of the agency, school, or hospital where you will be conducting your internship. Follow-up the in-person interviews you have had with telephone calls to inquire about the status of your request for an internship experience. Don’t wait for them to call you! Be persistent but do not be a “pest.”

7. Securing the Internship Site: It is strongly recommended that students only accept an offer of a counseling internship once they have completed a face-to-

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

8. Completing Necessary Paperwork: Upon securing an internship site, meet with the agency or school representative where you will be undertaking your

internship experience to complete necessary paperwork. There are two CES Program forms that need to be completed (including obtaining signatures) and there is one form of the Ohio CSW&MFT Board that needs to be completed. All KSU Clinical Mental Health Counseling students undertaking their internship must be registered with the Ohio CSW & MFT Board as a Counselor Trainee for the entirety of their internship.

A. CES Program Internship Forms (see item 9 below):

1. Internship Agreement signed by agency or school representative and student 2. Assigned Supervisor Qualifications form

B. Ohio CSW&MFT Board Form (see item 11 below): Professional Counselor Training Supervision Agreement (accessible on the Board’s website:

http://www.cswmft.ohio.gov under “Counselor Forms”). This form, once completed by the internship student and the internship site supervisor, needs to be submitted by the internship student directly to the Ohio CSW&MFT Board.

9. Submitting all Necessary Paperwork to the Master’s Practicum and Internship Coordinator: Please submit to the Master’s Practicum and Internship

Coordinator the following two forms: (1) the original (not a faxed copy) CES Internship Agreement form, and (2) the original (not a faxed copy) CES Assignment of Supervisor and Supervisor Qualifications Form. These two forms need to be completed (including signatures) and on file before you can begin your internship by the deadlines stated in item 3 above. Failure to submit necessary paperwork by the deadlines specified in this Manual may delay (by as much as an entire semester) the commencement of your internship experience.

10. Enrollment in Clinical Mental Health Counseling Internship Course: The Master’s Practicum and Internship Coordinator will enroll students in CES 77792:

Internship I: Clinical Mental Health Counseling Internship (3 credit hours) the first semester of internship and CES 77892: Internship II: Clinical Mental Health Counseling the second semester of internship. Enrollment will only take place when all required paperwork has been completed and submitted to the Internship Coordinator. Once enrolled in the first semester of the Clinical Mental Health Counseling Internship course, students will have the first two weeks of the first semester of their internship to verify to the Master’s Practicum and Internship Coordinator that they have earned a “Satisfactory” grade in their Practicum 2 course. If such a grade has not been earned in the first two weeks of the first semester of Internship I, the student will need to withdraw from Internship I.

11. Professional Counselor Training Supervision Agreement Form: This form is accessible on the Ohio CSW&MFT Board’s website:

http://www.cswmft.ohio.gov under “Counselor Forms.” All KSU Clinical Mental Health Counseling internship students are required to register with the licensure Board as a “Counselor Trainee.” This form should be completed with the student’s internship site supervisor and the form submitted directly to the Board prior to beginning internship. If approved by the Board, the student will be registered on the Board’s website as a “Counselor Trainee.” To verify status as a Counselor Trainee, please go to the Board’s website at http://www.cswmft.ohio.gov and click on “License Verification” (although “Counselor Trainee” is not a license). Please print a copy of your Counselor Trainee verification from the Board website and present this to the internship instructor on the first day of internship class each semester.

12. Completing State and Federal Criminal Background Checks: The Ohio CSW&MFT Board requires that all applicants for the Counselor Trainee status

complete state and federal criminal background checks. Results need to be sent directly to the Ohio CSW&MFT Board and the Ohio CSW&MFT Board needs to be the recipient of the results (i.e., a copy of results will not be accepted by the Board). Please consult the instructions on the licensure Board’s website for completing the Ohio Bureau of Criminal Identification and Investigation (BCI&I) and the Federal Bureau of Investigation (FBI) criminal records check.


KENT STATE UNIVERSITY CLINICAL MENTAL HEALTH COUNSELING PROGRAM

INTERNSHIP IN CLINICAL MENTAL HEALTH COUNSELING

INTERNSHIP ELIGIBILITY FORM Date Submitted to Master’s Practicum & Internship Coordinator: ______________ Master’s Practicum & Internship Coordinator’s Initials: ________________ This form is due June 15, if starting Fall semester; November 15, if starting Spring semester; or April 15, if starting Summer term. Read all directions carefully before completing the form. Type or print neatly all information needed. I. Identifying Information Name:_____________________________________________________________________________ Banner ID# ______________________________________ Current Postal Mailing Address: _________________________________________________________________________________________________________ Home Telephone Number: ________________________________________ Other Phone Number: __________________________________________________ E-Mail Address: ______________________________________________________________________________________________________________________ Semesters and Year(s) When Internship will be Undertaken (please check appropriate combination):

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

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

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

Month and Year of Expected Graduation: _________________________________________ II. Attach a Current and Original Academic Transcript This is available from the Registrar’s Office and should include all graduate courses completed to this date. III. Clinical Mental Health Counseling Courses Currently in Progress List all the courses in which you are currently enrolled. Include courses you are now taking and for which you have not received a final grade. You will need to verify the completion of all CACREP core area courses, as well as the additional internship prerequisite courses identified in this Internship Manual, before you can begin your internship experience. 1) _________________________________________2) _________________________________________3) _________________________________________ IV. Clinical Mental Health Counseling Courses To Be Completed List all the course work you plan to complete before graduation. Students cannot begin the internship experience if more than six (6) credit hours remain (excluding the 6 credit hours of CMHC Internship) on their Clinical Mental Health Counseling prospectus. V. Student Profile This information should be composed on a separate and printed double-spaced document addressing the following areas as they relate to your aspirations in the profession of counseling.

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

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

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

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

Student’s Signature: _______________________________________________________________________________ Date: __________________ CES Faculty Advisor’s Signature: _______________________________________________________________________________ Date: __________________ Accompanying Materials Needed: (a) Current and Original Academic Transcript of graduate studies; (b) Completed Student Profile; and (c) Professional Liability Insurance Policy (verifying current coverage)




CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP AGREEMENT Directions: This agreement is to verify for Kent State University (hereinafter referred to as “University”), the Internship Site (also referred to as “Agency”), and the student Intern (also referred to as “Counselor Trainee/Intern”) the expectations of the internship experience and to document that all parties have agreed to take part in this experience. The Internship Site (located in Ohio), the University, and the student Intern should receive a copy of the completed and signed form for their records. This agreement MUST be completed and signed by all appropriate parties, and the original agreement submitted (all pages of the original agreement) to the Master’s Practicum and Internship Coordinator by June 15, if starting Fall semester; November 15, if starting Spring semester; or April 15, if starting Summer term. This agreement between the Counselor Education and Supervision (CES) Program at Kent State University and __________________________________________________________________________ of _______________________, Ohio, is for the purpose of identifying

(Agency Name) (City)

responsibilities of all parties throughout the Clinical Mental Health Counseling Internship of ________________________________________________________ (Name of CES Clinical Mental Health Counseling Student)

while he/she is enrolled in and attending in person the weekly Clinical Mental Health Counseling Internship course for ___________________________________________________________________________________. (Semesters and Year[s] of Internship Experience and Internship Experience Course Attendance)

General Policies 1. The central purpose of this agreement is the formal education of students in preparation for practice as licensed Professional Counselors. 2. This agreement shall remain in effect for the duration of the student’s internship experience for the time period indicated at the agency specified above.

Termination of this agreement prior to the successful completion of internship requires the consultation of the assigned internship site supervisor, agency representative, Internship Instructor, Master’s Practicum and Internship Coordinator at the University, and the student. Similar consultation is required if the student secures an additional internship site.

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

while fulfilling internship duties; however, some agencies may offer stipends to interns. 4. The internship experience is to be undertaken and completed at an appropriate setting in Ohio and all Counselor Trainees/Interns must be registered with

the Ohio CSW&MFT Board as “Counselor Trainees” for the entirety of internship. Out-of-state internship experiences are not acceptable and weekly in-person attendance in the Clinical Mental Health Counseling Internship course is required.

5. Duration of internship is typically for two academic semesters (or one semester and a summer term), exclusive of vacations. Students may continue to

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

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

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

7. Internship hours shall be in accordance with agency work hours and shall total a minimum of 20 clock hours per week for a minimum total of 600 clock

hours at the conclusion of the internship experience. Of the 600 clock hours needed, a minimum of 240 clock hours must be in direct and face-to-face service to clients (and a minimum of 80 clock hours must be in individual face-to-face service to clients).

8. Weekly face-to-face individual supervision (approximately 1 hour/week) must be provided by a licensed Professional Clinical Counselor who has the

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

9. The internship experience must be clinical in nature. That is, Clinical Mental Health Counseling interns must have the opportunity to engage in the diagnosis

and treatment of mental disorders. Such services include, but are not limited to, psychological testing, diagnostic assessment, the provision of appropriate counseling interventions, and developing comprehensive and individualized treatment plans. This fulfills licensure eligibility requirements as a Professional Counselor in Ohio.


10. Students cannot begin accruing clock hours towards internship requirements until all agreement forms have been signed by all parties (i.e., CES faculty

advisor, site/clinical supervisor, Master’s Practicum and Internship Coordinator, and student intern), have been submitted in a timely fashion (according to deadlines specified in this Internship Manual) to the Master’s Practicum and Internship Coordinator, and the internship setting and experience have been determined as appropriate by the Master’s Practicum and Internship Coordinator. The earliest that students can begin accruing internship hours is on the first day of the academic semester or summer term in which the student is enrolled for internship. Vacations and holidays shall be observed according to the University calendar, unless otherwise agreed upon by the University representative, Agency, and student.

11. Students who are engaged in Clinical Mental Health Counseling internship-related activities and are enrolled in the Clinical Mental Health Counseling

internship course, are required to attend in-person weekly internship class sessions for the duration of their internship experience as determined by the time period indicated on the first and last pages of this agreement. Exceptions to this must be approved jointly by the Clinical Mental Health Counseling Internship Instructor and Master’s Practicum and Internship Coordinator, and methods for fulfilling all Internship requirements must be clarified before the beginning of the internship experience. Because the Clinical Mental Health Counseling Internship course is not an on-line or distance course, attendance by video conferencing or by using any other form of electronic communication is not acceptable.

Responsibilities of the University The University agrees to: 1. Assume full responsibility for the administrative duties associated with the academic requirements of the Clinical Mental Health Counseling Internship,

including approval of the Internship Site and experience, maintaining on-going and direct communication with Agency representatives, ensuring that Student Interns are academically ready to begin the Internship experience, and grading.

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

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

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

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

Responsibilities of the Agency

The Agency agrees to: 1. Designate one staff person as internship site supervisor with appropriate graduate degree and an independent mental health license. This person will be an

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

2. Develop work assignments and tasks for the Counselor Trainee/Intern commensurate with the CES Program objectives, in consultation with the CES

Internship Instructor and Master’s Practicum and Internship Coordinator. Furthermore, opportunities must be present for the student intern to become familiar with a variety of professional activities in addition to direct service (e.g. record keeping, supervision, information and referral, in-service and staff meetings).

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

and non-print media, professional literature, and research will be provided. 4. Ensure that at least 240 clock hours are devoted to direct, face-to-face service to clients, and that of these 240 hours, a minimum 80 clock hours are

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

5. Provide opportunities for the Counselor Trainee/Intern to engage in the provision of clinical services, namely the diagnosis and treatment of mental

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

6. If a Counselor Trainee/Intern is to engage in off-site services (e.g., home-based counseling, transportation of clients), proper training, safety measures (e.g.,

use of cell phone, obtaining immunization per Agency policy and at Agency expense, use of Agency vehicle only and only with adequate insurance coverage provided by the Agency), and appropriate supervision will be provided by the Agency. If the Counselor Trainee/Intern will be expected to provide such services, consultation with the Master’s Practicum and Internship Coordinator and/or Internship Instructor will be necessary prior to the commencement of such services.


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

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

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

8. Provide the minimum face-to-face supervisory requirements of one (1) hour for every 20 hours of overall service the student provides. Therefore, a 600-

hour internship would include a minimum of 30 hours of individual face-to-face supervision, with an additional hour for every 20 hours of internship activity beyond the 600 clock hour minimum. It is strongly recommended that a set day/time for weekly supervision be established.

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

materials with the Counselor Trainee/Intern. 10. Inform the University of Agency policies and procedures that are relevant to internship assignments and Counselor Trainee/Intern activities. 11. Maintain close communication with the University in relation to internship activities through available means such as internship site supervisor meetings,

correspondence with the Master’s Practicum and Internship Coordinator, on-site visits by the Internship Instructor, and telephone contacts. 12. Monitor Counselor Trainee/Intern performance and report to the University Internship Instructor and/or Master’s Practicum and Internship Coordinator

any difficulties in performance, ethics, or other internship related activities arise. 13. Allow the Counselor Trainee/Intern to attend weekly internship class sessions (usually held on Mondays, 7:20-10:0 p.m.) for the duration of his/her

internship experience (determined by the time period indicated on the first and last pages of this agreement).

Internship Student Responsibilities 1. The student intern will be enrolled in the Clinical Mental Health Counseling Internship course for each semester internship is undertaken (typically 3 credit

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

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

submit the originals on a weekly basis to the Clinical Mental Health Counseling Internship Instructor, and copies to the internship site/clinical supervisor. 3. The student intern will complete duties assigned and at hours scheduled at the internship site, according to the agreement established between the

student and agency representative. This includes fulfilling a minimum of 20 clock hours of internship activities per week, reporting directly to the internship site/clinical supervisor regarding client issues during regularly scheduled individual supervision sessions, and meeting with the internship site/clinical supervisor outside of regularly scheduled individual supervision sessions (e.g., in response to client crisis/emergency issues).

4. The student intern will be expected to conduct himself or herself in a professional manner expected of all Counselor Trainees and Professional Counselors

throughout the entirety of the internship experience. This means up-holding and abiding by the American Counseling Association's (ACA; 2005) ACA Code of Ethics [http://www.counseling.org], as well as the Code of Ethical Practice and Professional Conduct of the State of Ohio Counselor, Social Worker, and Marriage and Family Therapist Board (Rule 4757-5-01 of the ORC) [http://www.cswmft.ohio.gov].

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

deadlines specified in this Manual and in Internship class) and on file. 6. The student intern will be certain the internship site and assigned site/clinical supervisor receive a copy of the University calendar, student handbook, and

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

Agreement form and the Assigned Supervisor Qualifications form by June 15, if starting Fall semester; November 15, if starting Spring semester; or by April 15, if starting Summer term. The student will also be certain that the CES mid-internship evaluation form, CES final evaluation form, and the evaluation of the internship (Site and University) are properly completed and placed in the student’s internship file.

8. The student will purchase professional liability insurance and have proof of current coverage available throughout the internship experience. 9. The student will be registered as a “Counselor Trainee” with the Ohio CSW&MFT Board for the entirety of internship.


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

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

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

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

Agency Representative Agency Name, Address, and Telephone #: Signed: _____________________________________ ________________________________________ Printed: _____________________________________ ________________________________________ Title: _______________________________________ ________________________________________ Date: _______________________________________ (__________)______________________________ Student Master’s Practicum and Internship Coordinator Signed: ____________________________________ Signed: _________________________________ Printed: ____________________________________ Printed:_________________________________ Date: ______________________________________ Date:___________________________________




ASSIGNED SUPERVISOR QUALIFICATIONS FORM Directions: Please type or print CLEARLY all requested information. This form needs to be completed at or about the time the Internship Agreement Form is completed (i.e., by June 15, if starting Fall semester; November 15, if starting Spring semester; or April 15, if starting Summer term) and the original submitted to the Master’s Practicum and Internship Coordinator. Name of Clinical Mental Health Counseling Student Intern: Name, Address, and Phone # (with area code) of assigned Internship Site Supervisor: (or attach business card) Graduate Degree(s) of Internship Supervisor (include academic institution and date of earning degree(s)): Certificate(s) and License(s) of Internship Supervisor (include accrediting body and date of expiration): Internship will extend for _________ hours a week (minimum of 20 hours/week) for __________ weeks, totaling at least 600 clock hours of service, of which a minimum of 240 clock hours are devoted to direct, face-to-face service to clients (80 of which are in individual client contact). Clinical services will include the diagnosis and treatment of mental disorders. Minimum individual face-to-face supervision hours to be provided each week =1 hour of individual supervision for every 20 work hours. It is strongly recommended that a set day/time for weekly individual supervision be established for the entirety of internship. The Internship Site/Clinical Supervisor will assume full and direct legal responsibility for the welfare of all clients seen by the Student Intern. * Please attach a brochure of the agency/service organization. Internship Site/Clinical Supervisor’s Signature: __________________________________________________________ Date: _____________ Printed Internship Site/Clinical Supervisor’s Name: _____________________________________________________________________________ Agency Name: _____________________________________________________________________________ Student Intern’s Signature: __________________________________________________________ Date: _____________ Printed Student Intern’s Name: _____________________________________________________________________________ Master’s Practicum & Internship Coordinator’s Signature: __________________________________________________________ Date: _____________


Week # _________________



WEEKLY INTERN ACTIVITY REPORT & LOG


COUNSELOR EDUCATION AND SUPERVISION PROGRAM

CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP

WEEKLY INTERNSHIP LOG

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

Name: ______________________________________________________________________________ Week of:___________________ (month/day/year)

Agency Name:__________________________________________________ Site Supervisor:___________________________________________________

Activity Total Week Total to Date

Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)

Individual 0

Group 0

Family or couple 0

*Other (describe below) 0

Total Direct Service 0 0

Non-Direct Service

On-Site Supervision

Individual supervision 0

Group supervision 0

Subtotal for Supervision 0 0

Staff meetings 0

In-service training, workshop attendance 0

Documentation 0

Internship Class (2.5 hrs) 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:


II. WEEKLY ACTIVITY REPORT: Describe your assignment within the agency this week by responding to the following questions. Please be as specific as you can, citing appropriate and helpful examples. A. What specifically am I expected to do this week? B. In what ways is my assignment different than at the time of the last report? C. Mention specific learning or practice objectives that you and/or your supervisor have developed for you for this week. D. Delineate new areas of growth and development during this report period (please be specific). How will you apply these areas in the near future? E. Are there tasks or assignments which you would like to have added to your workload?


F. Describe any major practice problems you feel you are having. G. Assess your own performance during this report period. Please provide specific examples. III. Internship Concerns: Indicate any internship-related problems that you are experiencing. What steps have you already taken to resolve the problem? Is your site supervisor aware of this problem? Please indicate any matter that you feel requires the assistance of the internship instructor. IV. Internship Site/Clinical Supervisor’s Initials and Date: _______________________

Yes, I have reviewed this week’s activity report and log completed by the Clinical Mental Health Counseling Student Intern.

I request a phone call or a meeting with the KSU Clinical Mental Health Counseling Internship Instructor or Master’s Practicum and Internship Coordinator to discuss questions and/or concerns I have about this student’s internship.


CMHC Internship Skill Evaluation Form

Student Name: ______________________________________________________________________________________ Banner ID: _______________________ Person Completing Evaluation: __________________________________________________________________ Title: ___________________________________ Instructions:

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

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

Items scored as 4 -5 are considered acceptable. If any items are scored as 1 or 2, the instructor should discuss specific concerns with the student and ways the student can improve.

Standard 1 2 3 4 5 Score

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

The student cannot verbalize a need for self-care

The student cannot verbalize strategies for self-care

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

The student integrates self-care strategies but not continually

The student continually integrates and adapts new self-care strategies

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

5.b.1. Empathy

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

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

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

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

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

5.b.2. Unconditional Positive Regard

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

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

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

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

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

5.b.3. Congruence

Is incongruent among, self, thoughts, and actions

Is aware of incongruence among self, thoughts, and actions

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

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

Demonstrates consistent congruence among self, thoughts, and actions

5.C. Essential interviewing and counseling skills

5.c.1. Establishing Relationships

Shows no pattern for establishing a counseling relationship

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

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

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

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



5.C. Essential interviewing and counseling skills

5.c.1. Establishing Relationships

Shows no pattern for establishing a counseling relationship

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

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

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

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

5.c.2. Attending Does not practice attending behavior

Shows some inaccurate and inconsistent attending behaviors; visual contact, verbal tracking, vocal qualities, body language

Attending behavior is accurate but inconsistent; visual contact, verbal tracking, vocal qualities, body language

Attending behavior is mostly consistent and accurate; visual contact, verbal tracking, vocal qualities, body language

Attending behavior is accurate and complete

5.c.3. Questions Asks few questions or the questions do not appear to follow any logical pattern; does not verbally track client

Uses unintentional pattern of questions and does not follow logical pattern of client verbal tracking

Selects open and closed ended questions appropriately; does not follow client verbal tracking

Selects open and closed ended questions appropriately and mostly tracks client

Include questions appropriately; using closed and open ended questions and closely follows verbal tracking

5.c.4. Observation Skills

Makes no use of observation skills

Demonstrates some observational skills but does not show immediacy in response to the client

Uses observation skills but rarely uses immediacy in presenting them to the client

Uses appropriate observation skills with occasional immediacy

Uses appropriate observation skills and is able to show immediacy with them when working with a client

5.c.5. Encouraging Makes no use of encouraging skills

Rarely uses encouraging comments to client

Uses primarily non-verbal or minimal encouragers with client

Uses a range of encouragers (head nods, uh-huh, keywords, and short statements with client)

Intentionally uses a range of appropriate/timely encouraging skills with a client

5.c.6. Paraphrasing Paraphrases w/o intentionally using any of the four dimensions; sentence stem, keywords, essence, and check-out

Paraphrases and misses key points in client verbal tracking and components of the four dimensions

Paraphrases getting key verbal tracking but missing check-out and use of key words

Paraphrases w/ check-out but lacks full breath of the client story

Paraphrases using sentence stem, keywords, essence, and check-out

5.c.7. Summarizing Summarizes w/o intentionally using any of the four dimensions; sentence stem, keywords, essence, and check-out

Summarizes and misses key points in client verbal tracking and components of the four dimensions

Summarizes getting key verbal tracking but missing check-out and use of key words

Summarizes w/ check-out but lacks full breath of the client story

Summarizes using sentence stem, keywords, essence, and check-out

5.c.8. Ending a Session

Makes no use of skills to end a session

Summarizes end of session; there is little process other than to explain parts of what happened in the session; student assigns homework w/o client involvement

Summarizes end of session; includes check-out with client. student may or may not assign homework but w/o client involvement

Summarizes w/ checkout, may miss one of the following components; client strengths and continuity plan for next session. May or may not assign homework and does so with client involvement

Does complete summary, check-out, strengths, and continuity plan with client as part of summary



5.c.9. Reflection of Feelings

Does not reflect feelings

Attempts to reflect feelings but does so inaccurately

Reflects feelings inconsistently with varying levels of appropriateness

Consistently reflects feelings appropriately

Consistently reflects feelings appropriately and integrates it into case conceptualization

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

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

Always maintains appropriate confidentiality

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

Has minor boundary problems with clients

Has no boundary problems with clients

B.1.c. Record Keeping

Appropriate records are not kept

Records are kept infrequently, inaccurately and sloppily

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

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

Records are kept accurately and neatly at all times.

B.1.d. Areas of Competence

Consistently counsels clients outside many areas of expected developmental level

Often counsels clients outside many areas of expected developmental level

Sometimes counsels clients outside a few areas of expected developmental level

Rarely counsels clients outside any areas of expected developmental level

Never counsels clients outside any areas of expected developmental level

B.1.e. Counseling Minors

Always disregards client development and fails to inform care givers appropriately

Often disregards client development and fails to inform care givers appropriately

Sometimes disregards client development or fails to inform care givers appropriately

Rarely disregards client development or fails to inform care givers appropriately

Never disregards client development or fails to inform care givers appropriately

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

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

Never Rarely Sometimes Always Always and can integrate into treatment planning

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


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


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




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


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


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


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


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


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


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


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


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


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


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

Never Rarely Sometimes Often Always

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


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

Does not use nor understand strategies

Rarely uses or often misuses strategies

Sometimes uses or sometimes misuses strategies

Usually uses strategies appropriately

Always uses strategies appropriately

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

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


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


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


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


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




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

Does not recognize signs of suicide

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

Assesses or manages suicide risk in a basic or shallow manner (e.g., PIMP model)

Provides a thorough / comprehensive assessment of suicide risk (e.g., SIMPLE STEPS model); comprehensively manages suicide risk with short and long term goals for treatment – though is apprehensive and/or needs great amounts of supervision

Provides a thorough / comprehensive assessment of suicide risk (e.g., SIMPLE STEPS model); comprehensively manages suicide risk with short and long term goals for treatment

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

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


D.7.b. Record Security Never Rarely Sometimes Often Always

D.7.c. Accuracy Never Rarely Sometimes Often Always

D.7.d. Thoroughness Never Rarely Sometimes Often Always

D.7.e. Conciseness Never Rarely Sometimes Often Always

D.7.f. Makes documented links to treatment plan


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


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

D.9.a. Recognition of Limitations


D.9.b. Seeks supervision when necessary


D.9.c. Makes Appropriate Referrals


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

Never make referrals

Does not recognize when referrals are needed, but makes them after prompting

Usually recognizes the need for referrals and makes them after prompting

Usually recognizes the need for referrals and makes them appropriately

Always recognizes the need for referrals and makes them appropriately

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

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

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

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

Has basic knowledge and skill if effectively conducting an intake

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

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

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

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

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

Has basic knowledge and skill if effectively conducting an MSE

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

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



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

Never make referrals

Does not recognize when referrals are needed, but makes them after prompting

Usually recognizes the need for referrals and makes them after prompting

Usually recognizes the need for referrals and makes them appropriately

Always recognizes the need for referrals and makes them appropriately

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

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

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

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

Has basic knowledge and skill if effectively conducting an intake

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

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

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

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

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

Has basic knowledge and skill if effectively conducting an MSE

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

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

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

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

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

Has basic knowledge and skill if effectively conducting an BPS Hx

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

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

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

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

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

Has basic knowledge and skill if effectively conducting an MH Hx

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

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

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

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

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

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

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

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

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

H.3.a. Appropriately Screens for Addiction


H.3.b. Appropriately Screens for Aggression




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

H.3.a. Appropriately Screens for Addiction


H.3.b. Appropriately Screens for Aggression


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


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


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


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

Does not participate in this activity

Looks at research but does not understand it

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

Uses research to work with clients with minimal assistance

Uses research to work with clients independently

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


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


CES 1. Ability to structure a session intentionally


CES 2. Integrates multiple micro-skills fluidly


Provide 3-4 specific recommendations for continued professional growth and development in the space below (or attach a separate sheet): For Site Supervisors completing evaluation on Internship I students (Check One):

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

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

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

Student’s Signature: __________________________________________________________ Date: _____________ Site Supervisor’s Signature: __________________________________________________________ Date: _____________ Master’s Practicum & Internship Coordinator’s Signature: __________________________________________________________ Date: _____________


CMHC Internship Professional Behavior Evaluation Form

Student Name: ______________________________________________________________________________________ Banner ID: _______________________ Person Completing Evaluation: __________________________________________________________________________ Title: ___________________________ Instructions:

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

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

Please place a check in the appropriate box.

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

All scores contribute to the overall grade in this course.

Section A: Professional Behavior Never Occurs After Multiple

Corrections

Occurs After Multiple

Corrections

Occurs After Few

Corrections

Occurs After One Correction

Always occurs

Not Applicable

1 2 3 4 5 X

Dresses Appropriately

Is on time for appointments

Is on time to site

Interacts with colleagues in a professional manner

Interacts with office staff in a professional manner

Has professional demeanor on telephone with clients/parents

Completes record keeping in a timely manner

Treats clients with respect in waiting areas

Arrives at site on agreed dates and times

Calls to report inability to come to site in a timely and professional manner

Arrives prepared for supervision

Assists colleagues when appropriate and needed

Follows site guidelines / policies

Accepts feedback

Arrives prepared for client sessions

Takes initiative on projects when appropriate

Maintains proper personal hygiene

Section B: Professional Behavior Serious Concern Always

Discusses client cases only in appropriate settings

Maintains client confidentiality through proper record handling

Is respectful of all clients regardless of any differences

Complies with supervisor directions

Seeks supervision when needed

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

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

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

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

Student Signature: __________________________________________________________ Date: _____________ Site Supervisor’s Signature: __________________________________________________________ Date: _____________ Master’s Practicum & Internship Coordinator’s Signature: __________________________________________________________ Date: _____________

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



INTERN’S ASSESSMENT OF THE INTERNSHIP

Student Name: ______________________________________________________________________________________ Banner ID: _______________________ Person Completing Evaluation: __________________________________________________________________ Title: ___________________________________ This evaluation is for the purpose of providing feedback to the Site/Clinical Supervisor, the Agency, and the University regarding student perceptions of the internship experience. This instrument is designed as a guide to facilitate the sharing of the most significant perceptions and impressions that occur throughout the internship experience. As a student counselor and a beginning professional, you are urged to complete this instrument completely and honestly. You should already have begun this kind of critical sharing with your site/clinical supervisor, others in the Agency, and your faculty Internship Instructor. Your responses can aid your own professional development, and your assessment will significantly help the Agency and the University be even more responsive to student needs. 1. Complete the rating form as follows (circle appropriate responses for each item):

5 -- Indicates complete satisfaction or an extremely positive response with the item. Where behavior is referred to, the behavior was always present when appropriate.

4 -- Moderate satisfaction: Desired behavior or condition was frequently present. 3 -- Somewhat satisfied: Desired behavior or condition was sometimes absent.

2 -- Somewhat dissatisfied: Desired behavior or condition was often absent. 1 -- Extremely dissatisfied: Desired behavior or condition was seldom present.

X -- It is not possible to assess this item. 2. Provide written comments regarding those items for which you have a special concern. I. The Internship Process

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

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

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

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

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

5 4 3 2 1 X

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

II. The Agency Setting

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

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

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

III. Professional Development

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

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

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

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

5 4 3 2 1 X

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

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

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

5 4 3 2 1 X

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


IV. Direct Supervision

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Optional: Provide additional comments in the space below (or attach a separate sheet): The Site/Clinical Supervisor and Intern have been involved in an evaluation process that they have discussed with one another. Significant disagreement on the part of the Intern or Site/Clinical Supervisor regarding this assessment should be noted in writing and forwarded to the Internship Instructor as an addendum to this form. Student’s Signature: __________________________________________________________ Date: _____________ Evaluator’s Signature: __________________________________________________________ Date: _____________ Instructor’s Signature: __________________________________________________________ Date: _____________ Master’s Practicum & Internship Coordinator’s Signature: __________________________________________________________ Date: _____________



CLINICAL MENTAL HEALTH COUNSELING PROGRAM INTERNSHIP COMPLETION FORM

The following signatures indicate that_____________________________________________________________________________________________________ (Name of Student Intern) satisfactorily fulfilled the expectations of the internship experience and met all requirements of the Clinical Mental Health Counseling Master’s degree internship. Site Name and Address:________________________________________________________________________________________________________________

Total

Individual Client Contact Hours

Small Group Contact Hours

Group Client Contact Hours

Couple/Family Contact Hours

Other Contact Hours

Total # of Direct Client Contact Hours (Ind. & Group Combined + and Couple/Family Contact Hours)

Individual Supervision Hours

Group Supervision Hours (On-Site Supervision)

Internship Class (2.5 hrs.)

Total # of Supervision Hours (Ind. & Group Combined)

Other Non-Direct Hours

Total (All Client Contact, Supervision Combined, & Non-Direct)

Student (Print): __________________________________________________________ Student Signature: __________________________________________________________ Date: _____________ Site-Supervisor (Print): __________________________________________________________ Site-Supervisor’s Signature: __________________________________________________________ Date: _____________ Instructor (Print): __________________________________________________________ Instructor’s Signature: __________________________________________________________ Date: _____________ Master’s Practicum & Internship Coordinator’s Signature: __________________________________________________________ Date: _____________

CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP MANUAL · 2015-04-28 · in Clinical Mental Health...

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Transcript of CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP MANUAL · 2015-04-28 · in Clinical Mental Health...