Pre-Licensed Clinical Supervision Hours Log

Log individual and group supervision hours, direct client contact, and supervisor attestation for pre-licensed clinicians supporting licensure applications.

Log Details

• Log Period Start Date
• Log Period End Date
• Submission Type
• Supervision Format
• Licensure Track

Clinician Information

• Clinician Name
• Current Credential or Associate Status
• Worksite or Practice Name
• Internal Supervisee ID
  Optional internal identifier used by your organization, if applicable.

Supervision Session Summary

• Session Date
• Session Type
• Session Duration (Minutes)
• Supervisor Name
• Supervisor License Type

Hours and Case Focus

• Direct Client Contact Hours
  Enter the number of hours spent in direct client contact for the log period.
• Supervision Hours
• Group Supervision Hours
• Case Focus Summary
  Briefly describe the clinical themes or competencies addressed. Do not include full client names or unnecessary PII.

Supervisor Attestation

• Supervisor Attestation
• Supervisor Signature
• Supervisor Signature Date
• Additional Notes