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