Counselor Education Program

Clinical Experience Hours

Instructions: You must submit signed copies (i.e., signed by your supervisor) of your total hour logs for each semester of clinical experiences (practicum and internship) along with this summary report (scanned and legible copies are appropriate). Additionally, if you are applying for a Marriage & Family Therapy license, be sure to attach the appropriate verification document(s) that demonstrate you have met the 180 hour marriage and family services requirement. Upon receipt of these documents, the Program will generate a letter verifying your completed hours to the State of your choosing. Please send this completed form and all other documents as email attachments to .

Full Name:

PID (used to confirm passing grades on all clinical experience courses):

Last 4 digits of your Social Security # (placed on the letter for the state):

State to which you are applying for licensure:

Address for the Licensing Board to which you are applying:

License for which you are applying (mental health, marriage & family, or both):

Practicum: UCF Counseling Clinic

MHS 6803 Practicum in Counselor Education I (all programs)

Semester/year completed:

·  Direct client contact hours:

·  Indirect client contact hours:

·  Total Practicum I hours:

MHS 6803 Practicum in Counselor Education II (MH & MFT)

Semester/year completed:

·  Direct client contact hours:

·  Indirect client contact hours:

·  Total Practicum II hours:

Grand Total of Practicum Hours:

·  Direct client contact hours:

·  Indirect client contact hours:

·  Total Practicum I and II hours:

Internship I: Site name, contact person, and phone number:

MHS 6830/SDS 6947 Counseling Internship I

Semester/year completed:

·  Direct client contact hours:

·  Indirect client contact hours:

·  Total Internship I hours:

Internship II: Site name, contact person, and phone number:

MHS 6830/SDS 6947 Counseling Internship II

Semester/year completed:

·  Direct client contact hours:

·  Indirect client contact hours:

·  Total Internship II hours:

Grand Total Internship Hours:

·  Direct client contact hours:

·  Indirect client contact hours:

·  Total Internship hours:

GRAND TOTAL PRACTICUM AND INTERNSHIP HOURS:

·  Direct client contact hours:

·  Indirect client contact hours:

·  Total Practicum and Internship hours: