Clinical Intern and Student Supervision Log

Log supervision sessions, competency development, and accrued hours for therapy interns and clinical students to support academic program requirements.

Log Entry Details

• Supervision Date
• Supervision Time
• Session Type
• Supervision Mode
• Location or Platform
  Enter the site name or virtual platform used for the session.
• Supervisor Name
  Enter the supervising clinician's name for recordkeeping.
• Supervisor Credentials
  Examples: LPC, LCSW, LMFT, OT, SLP, or other applicable credential.

Student or Intern Information

• Trainee Name
  Use the trainee's preferred professional name if that is how records are maintained.
• Trainee Role
• Academic Program
  Enter the school or training program name if needed for verification.
• Training Level

Hours and Competency Review

• Direct Supervision Hours
  Enter the number of hours spent in direct supervision for this log entry.
• Indirect Supervision Hours
  Enter time spent reviewing notes, recordings, or case materials outside live supervision.
• Competencies Reviewed
• Competency Notes
  Summarize strengths, coaching points, and any competency gaps identified.
• Student Progress Rating

Case Focus and Follow-Up

• Case or Topic Summary
  Briefly describe the case discussion, training topic, or skill reviewed without including unnecessary PII.
• Follow-Up Required?
• Follow-Up Actions
  Describe any assignments, additional observation, remediation, or documentation needed before the next supervision session.
• Next Review Date

Attestation and Submission

• Data Use Acknowledgment
  This form should only collect information needed for supervision documentation and audit trail purposes.
• Accuracy Attestation
• Supervisor Signature
• Trainee Signature
  Use if your academic program requires trainee acknowledgment.