Clinical Forms

Additional Forms This page has several additional forms that you will need during your clinical experience. To obtain these forms clink on the link below, then copy and print them. Clinical Experiences Summary of Hours Weekly Time Log Case study form Case Conference Form Weekly Time Log

in process Northeastern Illinois University Department of Counselor Education Clinical Experiences Summary of Hours Student Name___________________________ Semester/year_______________________________

Name of site____________________________________ Site Supervisor ______________________________

University Supervisor __________________________________ Practicum Internship I Internship II
(Circle one)

____________________________________________________Practicum Internship I Internship II_______
Direct Service Hours

1.    Individual Counseling                                                        ____________     __________    ___________
2.    Family Counseling                                                             ____________     __________    ___________
3    Group Counseling                                                              ____________     __________    ___________
4.   Guidance Activities                                                            .____________     __________    ___________
                                            Totals                                           ____________     __________    ___________
                                                        Overall total                                                                           ___________
__________________________________________________________________________________________
Site Supervision

1.    Individual                                                                        ____________     __________    ___________
2.    Group                                                                            ____________     __________    ___________
                                                Totals                                     ____________     __________    ___________
                                                            Overall Total                                                                  _____________

______________________________________________________________________________________
University Supervision

1.    Individual                                                                        ____________     __________    ___________
2.    Group                                                                            ____________     __________    ___________
                                                Totals                                     ____________     __________    ___________
                                                            Overall Total                                                                  ____________
_____________________________________________________________________________________
Other

1. Include professional development, report writing at site,
    observation, etc., and other administrative duties.
                                Semester overall hours                            ____________     __________    ___________
                                            Overall total                                                                                  ____________

I verify that the above named student has had the amount of direct service and supervision indicated on this form.

_____________________________________ ____________________________________
Site supervisor University supervisor

Students are to maintain this record throughout their clinical experiences, and submit two copies to their university supervisor, one of which is to be placed in their student file. Students should also retain a copy for their own records.