College of Education, Health, & Human Services
Counselor Education and Supervision (CES) Program
CLINICAL MENTAL HEALTH COUNSELING
INTERNSHIP MANUAL
TABLE OF CONTENTS
Item
Internship Planning Process
Internship Eligibility Form
Internship Agreement
Assigned Supervisor Qualifications Form
Reporting: Weekly Internship Log and Activity Report
CMHC Internship Skill Evaluation Form
CMHC Internship Professional Behavior Evaluation
Form
Interns Assessment of the Internship
Internship Completion Form
Page
2-3
4
5-8
9
10-12
13-22
Due weekly in internship class / seminar
Due at the end of Internship I and Internship II
20
Due at the end of Internship I and Internship II
21-22
23
Deadline



June 15 (if starting in Fall semester)
November 15 (if starting in Spring semester)
April 15 (if starting in Summer term)
Due at end of internship
Due at end of internship
For information contact:
Dr. Lynne Guillot-Miller
Coordinator of the Master’s Degree Program in Clinical Mental Health Counseling
OR
Dr. Steve Rainey
Master’s Practicum and Internship Coordinator
310 White Hall, College of Education, Kent State University, Kent, OH 44242
(330) 672-2662 * * * * FAX (330) 672-2472
KENT STATE UNIVERSITY
Revised April 2015
Page 1 of 23
CLINICAL MENTAL HEALTH COUNSELING PROGRAM
INTERNSHIP IN CLINICAL MENTAL HEALTH COUNSELING
INTERNSHIP PLANNING PROCESS
The internship experience represents the culmination of formal academic training in the Clinical Mental Health Counseling program. It is the opportunity students
have to assume the role of professional counselor-in-training (i.e., “Counselor Trainee”) and to provide clinical services within a community agency, school,
hospital, private group practice, or college counseling facility under appropriate supervision. The internship experience is also an “opportunity for the student to
become familiar with a variety of professional activities and resources in addition to direct service (e.g., record keeping, assessment instruments, supervision,
information and referral, in-service and staff meetings)” (CACREP, 2009, p. 16). According to Ohio counselor licensure law, students can only practice as
“Counselor Trainees” when they are enrolled in either counseling practicum or internship courses and are receiving appropriate face-to-face supervision. The
Counselor Education and Supervision (CES) Program further requires that all Clinical Mental Health Counseling students preparing for internship register with the
Ohio Counselor, Social Worker, and Marriage and Family Therapist Board (Ohio CSW&MFT Board) as a “Counselor Trainee” prior to beginning internship. The
internship experience, therefore, serves as a “testing ground” of sorts. Students have the opportunity to test the academic course work and formal training
received thus far and students are themselves challenged to practice, in the role of Counselor Trainee/Intern, the counseling theories, techniques, and
procedures learned in their program.
Internship is undertaken at the conclusion of the student’s program, with no more than 6 credit hours remaining to complete the 60-credit hour master’s degree
in Clinical Mental Health Counseling (excluding the 6 credit hours required for internship). The internship is undertaken over two semesters (or one semester and
one summer term) and therefore students will be enrolled for 3 credit hours of internship for each of the two semesters of their internship experience. Students
will not be able to undertake their entire internship in one semester and therefore will not be enrolled for 6 credit hours of internship in one semester.
The CES Faculty have determined that all CACREP core area courses (as listed on the Clinical Mental Health Counseling prospectus) need to be completed prior
to the start of internship. Four additional courses are also prerequisites to internship:
_____
_____
_____
_____
CES 6/77628: Diagnosis in Counseling
CES 6/78130: Psychopathology for Counselors
CES 6/77492: Practicum I
CES 6/77592: Practicum II
Successful completion of all CACREP core area courses and the four courses listed above needs to be verified on the student’s academic transcript.
It is important that each student identifies and selects an internship setting that suits his or her learning requirements. In order to accomplish this, considerable
planning and careful preparation must be completed before the student actually begins the internship experience. The internship experience must provide the
student with opportunities to engage in clinical counseling services; that is, the student must engage in the diagnosis and treatment of mental disorders, under
the supervision of a licensed Professional Clinical Counselor (PCC) who has the supervisory endorsement of the Ohio CSW&MFT Board (PCC-S credential). Clinical
services provided during internship include, but are not limited to, screening clients for treatment eligibility, conducting comprehensive assessments,
determining DSM diagnoses, providing appropriate treatment interventions to clients, and constructing individualized treatment plans. The clinical nature of the
internship experience fulfills licensure eligibility requirements in the state of Ohio. The Clinical Mental Health Counseling internship experience must therefore be
undertaken and completed in Ohio. Once a potential internship site has been located by a student, the Master’s Practicum and Internship Coordinator will need
to verify the appropriateness of the setting and supervision prior to the student beginning his or her internship experience (this usually entails telephone contact
with the proposed site supervisor or appropriate representative of the proposed internship site).
What follows is a step-by-step process for students to follow in identifying and securing an internship setting and experience. As a student, it is your
responsibility to begin the process early (i.e., at least one full semester prior to the beginning of the internship experience). This means completing the Internship
Eligibility Form and meeting with your CES faculty advisor to review and sign it. Your careful attention to the Internship Eligibility Form will ensure that the
internship location process begins smoothly and will help ensure that you identify an appropriate setting. If you have questions about completing the internship
materials, contact your CES faculty advisor or the Master’s Practicum and Internship Coordinator.
Step-by-Step Directions
1.
Complete Internship Eligibility Form: The first step of the internship application process is completing the Internship Eligibility Form, found within this
Internship Manual, with the three (3) necessary accompanying materials: (a) current academic transcript, (b) Student Profile, and (c) Professional Liability
Insurance Policy. Your completion of this form will help to clarify your needs and goals for the internship experience and will help identify an appropriate
internship placement. You will need to have completed the Internship Eligibility Form (and the three necessary accompanying materials) before meeting
with your CES faculty advisor. His or her signature on the form indicates that you are academically ready to begin the internship experience at the start of
the semester (or summer term) you have indicated.
2.
Meet with CES Faculty Advisor: The next step in the process of locating an internship site is meeting with your CES faculty advisor and discussing your
Internship Eligibility Form. It is recommended that you schedule an appointment and meet face-to-face with your CES faculty advisor early in the semester
prior to the beginning of your proposed internship experience. Once the Internship Eligibility Form has been reviewed by your faculty advisor, obtain
his/her signature, and make a copy of the form for yourself.
3.
Submit Completed Internship Eligibility Form to Master’s Practicum & Internship Coordinator: A copy of the Internship Eligibility Form, signed and dated
by both you and your CES faculty advisor, along with the three necessary accompanying materials (i.e., current academic transcript, Student Profile, and
Professional Liability Insurance Policy), are due to the Master’s Practicum and Internship Coordinator by June 15, if starting Fall semester; November 15, if
starting Spring semester; or April 15, if starting in the Summer term.
4.
Obtain List of Potential Internship Sites in Ohio: A list of potential internship sites in Ohio (primarily Northeast Ohio) is available in the CES office, 310
White Hall. It is the student’s responsibility to contact and secure an internship site and the site must be in Ohio. Your CES faculty advisor and the Master’s
Practicum and Internship Coordinator can assist in identifying and recommending particular sites. However, it will be your responsibility to initiate contact
Revised April 2015
Page 2 of 23
with potential internship sites, schedule interviews, and finalize the internship agreement.
5.
Contact Potential Internship Sites: Once you have identified several potential internship sites in Ohio (as a result of conferring with your CES academic
advisor and/or the Master’s Practicum and Internship Coordinator), it is recommended that you begin making telephone calls and scheduling appointments
early in the process (i.e., at the very beginning of the semester prior to the start of your proposed internship). When you call each agency/organization, ask
to speak directly with the clinical director and/or internship coordinator; inquire about the specific clinical services provided by each agency, school, or
hospital that a counseling intern would be able to offer (e.g., psychological testing, diagnostic assessment, treatment planning, conducting individual
counseling sessions so as to accrue a minimum of 80 individual direct or face-to-face clock hours); and request an on-site interview for a possible internship
experience. It is strongly recommended that you make the initial contact by telephone and only use email communication to follow-up a voice mail
message left for the contact person or when advised to use email by the contact person. In addition, do not base an internship agreement on a telephone
interview! Schedule an on-site interview with the agency contact person and meet directly with this person. Take a copy of this Clinical Mental Health
Counseling Internship Manual and your resume with you. Keep track of the agencies and persons you contact and be certain you know with whom you are
speaking and his/her title, credentials (graduate degree, professional license), and position at the agency.
6.
Interview Guidelines: Once an interview has been scheduled, arrive on time for the scheduled interview. Do not be a “no show”! Remember, you are
representing the Clinical Mental Health Counseling program at KSU. Take with you to the interview a copy of your current resume and a copy of this Clinical
Mental Health Counseling Internship Manual to leave with the person with whom you will be interviewing. Provide that person with the name and
telephone number of the Master’s Practicum and Internship Coordinator. Clarify that individual and face-to-face weekly supervision will need to be
provided by a licensed Professional Clinical Counselor (PCC-S) who has the supervisory endorsement of the Ohio CSW&MFT Board, and who is an employee
(part-time, full-time, or contracted with the agency) of the agency, school, or hospital where you will be conducting your internship. Follow-up the inperson interviews you have had with telephone calls to inquire about the status of your request for an internship experience. Don’t wait for them to call
you! Be persistent but do not be a “pest.”
7.
Securing the Internship Site: It is strongly recommended that students only accept an offer of a counseling internship once they have completed a face-toface interview with the appropriate person at the internship site. If you have received more than one offer of a counseling internship, it is imperative that
you inform the site(s) whose offer you will not be accepting that you have accepted an offer at another internship site and therefore will be declining that
offer. Furthermore, if you have verbally accepted an internship offer, you need to follow-through and finalize the internship agreement in writing. If for
various reasons you need to decline an offer that you initially accepted, it is imperative that you speak directly with the person who offered you the
internship position and explain your reason(s) for reneging on the verbal agreement you made earlier. Remember that you are not only representing the
Clinical Mental Health Counseling program at KSU, you are also engaging in professional behavior and therefore making impressions to prospective
employers.
8.
Completing Necessary Paperwork: Upon securing an internship site, meet with the agency or school representative where you will be undertaking your
internship experience to complete necessary paperwork. There are two CES Program forms that need to be completed (including obtaining signatures) and
there is one form of the Ohio CSW&MFT Board that needs to be completed. All KSU Clinical Mental Health Counseling students undertaking their internship
must be registered with the Ohio CSW & MFT Board as a Counselor Trainee for the entirety of their internship.
9.
A.
CES Program Internship Forms (see item 9 below):
1. Internship Agreement signed by agency or school representative and student
2. Assigned Supervisor Qualifications form
B.
Ohio CSW&MFT Board Form (see item 11 below): Professional Counselor Training Supervision Agreement (accessible on the Board’s website:
http://www.cswmft.ohio.gov under “Counselor Forms”). This form, once completed by the internship student and the internship site supervisor,
needs to be submitted by the internship student directly to the Ohio CSW&MFT Board.
Submitting all Necessary Paperwork to the Master’s Practicum and Internship Coordinator: Please submit to the Master’s Practicum and Internship
Coordinator the following two forms: (1) the original (not a faxed copy) CES Internship Agreement form, and (2) the original (not a faxed copy) CES
Assignment of Supervisor and Supervisor Qualifications Form. These two forms need to be completed (including signatures) and on file before you can
begin your internship by the deadlines stated in item 3 above. Failure to submit necessary paperwork by the deadlines specified in this Manual may delay
(by as much as an entire semester) the commencement of your internship experience.
10. Enrollment in Clinical Mental Health Counseling Internship Course: The Master’s Practicum and Internship Coordinator will enroll students in CES 77792:
Internship I: Clinical Mental Health Counseling Internship (3 credit hours) the first semester of internship and CES 77892: Internship II: Clinical Mental
Health Counseling the second semester of internship. Enrollment will only take place when all required paperwork has been completed and submitted to
the Internship Coordinator. Once enrolled in the first semester of the Clinical Mental Health Counseling Internship course, students will have the first two
weeks of the first semester of their internship to verify to the Master’s Practicum and Internship Coordinator that they have earned a “Satisfactory” grade
in their Practicum 2 course. If such a grade has not been earned in the first two weeks of the first semester of Internship I, the student will need to
withdraw from Internship I.
11. Professional Counselor Training Supervision Agreement Form: This form is accessible on the Ohio CSW&MFT Board’s website:
http://www.cswmft.ohio.gov under “Counselor Forms.” All KSU Clinical Mental Health Counseling internship students are required to register with the
licensure Board as a “Counselor Trainee.” This form should be completed with the student’s internship site supervisor and the form submitted directly to
the Board prior to beginning internship. If approved by the Board, the student will be registered on the Board’s website as a “Counselor Trainee.” To verify
status as a Counselor Trainee, please go to the Board’s website at http://www.cswmft.ohio.gov and click on “License Verification” (although “Counselor
Trainee” is not a license). Please print a copy of your Counselor Trainee verification from the Board website and present this to the internship instructor on
the first day of internship class each semester.
12. Completing State and Federal Criminal Background Checks: The Ohio CSW&MFT Board requires that all applicants for the Counselor Trainee status
complete state and federal criminal background checks. Results need to be sent directly to the Ohio CSW&MFT Board and the Ohio CSW&MFT Board needs
to be the recipient of the results (i.e., a copy of results will not be accepted by the Board). Please consult the instructions on the licensure Board’s website
for completing the Ohio Bureau of Criminal Identification and Investigation (BCI&I) and the Federal Bureau of Investigation (FBI) criminal records check.
Revised April 2015
Page 3 of 23
KENT STATE UNIVERSITY
CLINICAL MENTAL HEALTH COUNSELING PROGRAM
INTERNSHIP IN CLINICAL MENTAL HEALTH COUNSELING
INTERNSHIP ELIGIBILITY FORM
Date Submitted to Master’s Practicum & Internship Coordinator: ______________



Master’s Practicum & Internship Coordinator’s Initials: ________________
This form is due June 15, if starting Fall semester; November 15, if starting Spring semester; or April 15, if starting Summer term.
Read all directions carefully before completing the form.
Type or print neatly all information needed.
I. Identifying Information
Name:_____________________________________________________________________________ Banner ID# ______________________________________
Current Postal Mailing Address: _________________________________________________________________________________________________________
Home Telephone Number: ________________________________________ Other Phone Number: __________________________________________________
E-Mail Address: ______________________________________________________________________________________________________________________
Semesters and Year(s) When Internship will be Undertaken (please check appropriate combination):

Fall _________ and Spring _________ (approx. 36 weeks total, including Fall final exam week, 4-week winter break, and Spring break)

Spring ________ and Summer ________ (approx. 31 weeks total, including Spring break, Spring final exam week, 4-week spring/summer intersession,
and 10 week summer term)

Summer ________ and Fall ________ (approx. 26 weeks total, including 10-week summer term, one week in-between summer term and start of Fall
semester)
Month and Year of Expected Graduation: _________________________________________
II. Attach a Current and Original Academic Transcript This is available from the Registrar’s Office and should include all graduate courses completed to this date.
III. Clinical Mental Health Counseling Courses Currently in Progress List all the courses in which you are currently enrolled. Include courses you are now taking
and for which you have not received a final grade. You will need to verify the completion of all CACREP core area courses, as well as the additional internship
prerequisite courses identified in this Internship Manual, before you can begin your internship experience.
1) _________________________________________2) _________________________________________3) _________________________________________
IV. Clinical Mental Health Counseling Courses To Be Completed List all the course work you plan to complete before graduation. Students cannot begin the
internship experience if more than six (6) credit hours remain (excluding the 6 credit hours of CMHC Internship) on their Clinical Mental Health Counseling
prospectus.
V. Student Profile This information should be composed on a separate and printed double-spaced document addressing the following areas as they relate to
your aspirations in the profession of counseling.
1.
2.
3.
4.
Preferred internship setting, population served, and overall experience. Please describe the type of internship setting, type of population served, and
overall internship experience that you prefer. Please discuss how your proposed internship experience will be clinical in nature (i.e., include the
diagnosis and treatment of mental disorders under clinical supervision).
Experience relevant to Clinical Mental Health Counseling: Describe paid or volunteer activities through which you have gained experience helpful to a
counseling career. This is general, so consider any experiences that demonstrate your potential to work with people, such as a residence hall advisor,
crisis hotline volunteer, or other related activities. You may attach a copy of your resume.
Post-graduation plans: Indicate your employment aspirations, plans for further study, or other expectations that have a bearing on your future as a
professional counselor.
Describe what goals or educational objectives you hope to accomplish through the internship experience. What strengths do you take with you into
this internship experience? What areas are you aware of that need further work? Specify if you are interested in certain client groups or specific
treatment approaches.
Student’s Signature:
_______________________________________________________________________________
CES Faculty Advisor’s Signature: _______________________________________________________________________________
Date: __________________
Date: __________________
Accompanying Materials Needed: (a) Current and Original Academic Transcript of graduate studies; (b) Completed Student Profile; and (c) Professional Liability
Insurance Policy (verifying current coverage)
Revised April 2015
Page 4 of 23
KENT STATE UNIVERSITY
CLINICAL MENTAL HEALTH COUNSELING PROGRAM
INTERNSHIP IN CLINICAL MENTAL HEALTH COUNSELING
CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP AGREEMENT
Directions: This agreement is to verify for Kent State University (hereinafter referred to as “University”), the Internship Site (also referred to as “Agency”), and
the student Intern (also referred to as “Counselor Trainee/Intern”) the expectations of the internship experience and to document that all parties have agreed to
take part in this experience. The Internship Site (located in Ohio), the University, and the student Intern should receive a copy of the completed and signed form
for their records. This agreement MUST be completed and signed by all appropriate parties, and the original agreement submitted (all pages of the original
agreement) to the Master’s Practicum and Internship Coordinator by June 15, if starting Fall semester; November 15, if starting Spring semester; or April 15, if
starting Summer term.
This agreement between the Counselor Education and Supervision (CES) Program at Kent State University and
__________________________________________________________________________ of _______________________, Ohio, is for the purpose of identifying
(Agency Name)
(City)
responsibilities of all parties throughout the Clinical Mental Health Counseling Internship of ________________________________________________________
(Name of CES Clinical Mental Health Counseling Student)
while he/she is enrolled in and attending in person the weekly Clinical Mental Health Counseling Internship course for
___________________________________________________________________________________.
(Semesters and Year[s] of Internship Experience and Internship Experience Course Attendance)
General Policies
1.
The central purpose of this agreement is the formal education of students in preparation for practice as licensed Professional Counselors.
2.
This agreement shall remain in effect for the duration of the student’s internship experience for the time period indicated at the agency specified above.
Termination of this agreement prior to the successful completion of internship requires the consultation of the assigned internship site supervisor, agency
representative, Internship Instructor, Master’s Practicum and Internship Coordinator at the University, and the student. Similar consultation is required if
the student secures an additional internship site.
3.
The internship experience is typically a voluntary arrangement with no financial remuneration required by the University or Agency for services provided
while fulfilling internship duties; however, some agencies may offer stipends to interns.
4.
The internship experience is to be undertaken and completed at an appropriate setting in Ohio and all Counselor Trainees/Interns must be registered with
the Ohio CSW&MFT Board as “Counselor Trainees” for the entirety of internship. Out-of-state internship experiences are not acceptable and weekly inperson attendance in the Clinical Mental Health Counseling Internship course is required.
5.
Duration of internship is typically for two academic semesters (or one semester and a summer term), exclusive of vacations. Students may continue to
practice as a Counselor Trainee/Intern at the internship setting during academic breaks at the university (e.g., spring break, winter break, spring/summer
intersession) only as long as the student remains continuously enrolled in a section of Clinical Mental Health Counseling Internship. Internship undertaken
for the Fall and Spring semesters is approximately 36 weeks; for Spring semester and summer term, the length of internship is approximately 31 weeks; and
for summer term and Fall semester, the length of internship is approximately 26 weeks.
6.
Once all necessary paperwork and completed forms have been submitted to the Master’s Practicum and Internship Coordinator by the deadline specified in
this Manual, and the Master’s Practicum and Internship Coordinator has determined (in consultation with agency representative) that the proposed
internship site and experience are appropriate for fulfilling both CES Clinical Mental Health Counseling program and state licensure eligibility requirements,
the student will be enrolled for 3 credit hours in the Clinical Mental Health Counseling Internship course for each semester he/she is undertaking the
internship experience. Students will need to withdraw from the Clinical Mental Health Counseling Internship course within the first two weeks of the first
semester of internship if they have yet to earn a Satisfactory grade for Practicum 2.
7.
Internship hours shall be in accordance with agency work hours and shall total a minimum of 20 clock hours per week for a minimum total of 600 clock
hours at the conclusion of the internship experience. Of the 600 clock hours needed, a minimum of 240 clock hours must be in direct and face-to-face
service to clients (and a minimum of 80 clock hours must be in individual face-to-face service to clients).
8.
Weekly face-to-face individual supervision (approximately 1 hour/week) must be provided by a licensed Professional Clinical Counselor who has the
supervisory endorsement of the Ohio Counselor, Social Worker, and Marriage and Family Therapist Board (Ohio SWMFT Board), and who is an employee
(part-time, full-time, or contracted with the agency) of the agency, school, or hospital where the Clinical Mental Health Counseling student is undertaking
his/her internship experience. One hour of individual supervision must be provided for every 20 hours of internship activity. Therefore, a 600-hour
internship would include a minimum of 30 hours of face-to-face individual supervision, with an additional hour for every 20 hours of internship activity
beyond the 600 clock hour minimum. It is strongly recommended that a set day/time for weekly individual supervision be established.
9.
The internship experience must be clinical in nature. That is, Clinical Mental Health Counseling interns must have the opportunity to engage in the diagnosis
and treatment of mental disorders. Such services include, but are not limited to, psychological testing, diagnostic assessment, the provision of appropriate
counseling interventions, and developing comprehensive and individualized treatment plans. This fulfills licensure eligibility requirements as a Professional
Counselor in Ohio.
Revised April 2015
Page 5 of 23
10. Students cannot begin accruing clock hours towards internship requirements until all agreement forms have been signed by all parties (i.e., CES faculty
advisor, site/clinical supervisor, Master’s Practicum and Internship Coordinator, and student intern), have been submitted in a timely fashion (according to
deadlines specified in this Internship Manual) to the Master’s Practicum and Internship Coordinator, and the internship setting and experience have been
determined as appropriate by the Master’s Practicum and Internship Coordinator. The earliest that students can begin accruing internship hours is on the
first day of the academic semester or summer term in which the student is enrolled for internship. Vacations and holidays shall be observed according to
the University calendar, unless otherwise agreed upon by the University representative, Agency, and student.
11. Students who are engaged in Clinical Mental Health Counseling internship-related activities and are enrolled in the Clinical Mental Health Counseling
internship course, are required to attend in-person weekly internship class sessions for the duration of their internship experience as determined by the
time period indicated on the first and last pages of this agreement. Exceptions to this must be approved jointly by the Clinical Mental Health Counseling
Internship Instructor and Master’s Practicum and Internship Coordinator, and methods for fulfilling all Internship requirements must be clarified before the
beginning of the internship experience. Because the Clinical Mental Health Counseling Internship course is not an on-line or distance course, attendance by
video conferencing or by using any other form of electronic communication is not acceptable.
Responsibilities of the University
The University agrees to:
1.
Assume full responsibility for the administrative duties associated with the academic requirements of the Clinical Mental Health Counseling Internship,
including approval of the Internship Site and experience, maintaining on-going and direct communication with Agency representatives, ensuring that
Student Interns are academically ready to begin the Internship experience, and grading.
2.
Provide information regarding the CES Clinical Mental Health Counseling program and curriculum in order that the Agency may properly plan and execute
task assignments and supervision. Specifically included are student data, university calendar, student handbook, and the Clinical Mental Health Counseling
Internship Manual.
3.
Designate one CES faculty member each academic semester who will be the Internship Instructor for the Student and who will communicate directly with
the internship site supervisor (by telephone contact and possibly an internship site visit). The Instructor will lead and facilitate weekly Clinical Mental Health
Counseling Internship class sessions (2.5 hours/week) to which all student interns will be required to attend in-person, and will be available for consultation
with the internship site supervisor and students for the duration of their internship experience. The role of the Internship Instructor and the Master’s
Practicum and Internship Coordinator will be that of a consultant alone; the designated internship site supervisor will assume legal responsibility for all
clients seen by the student intern.
Responsibilities of the Agency
The Agency agrees to:
1.
Designate one staff person as internship site supervisor with appropriate graduate degree and an independent mental health license. This person will be an
employee (part-time, full-time, or contracted with the agency) of the Agency where the internship will be conducted. Internship site supervisors of all
counseling interns must hold the license of Professional Clinical Counselor (PCC) in Ohio and must have the supervisory endorsement of the Ohio CSW&MFT
Board (i.e., PCC-S designation) at the beginning and for the duration of the student’s internship experience. The designated internship site supervisor will
assume legal responsibility for the welfare of all clients seen by the student intern.
2.
Develop work assignments and tasks for the Counselor Trainee/Intern commensurate with the CES Program objectives, in consultation with the CES
Internship Instructor and Master’s Practicum and Internship Coordinator. Furthermore, opportunities must be present for the student intern to become
familiar with a variety of professional activities in addition to direct service (e.g. record keeping, supervision, information and referral, in-service and staff
meetings).
3.
The opportunity for the Counselor Trainee/Intern to gain experience in the use of a variety of professional resources such as assessment instruments, print
and non-print media, professional literature, and research will be provided.
4.
Ensure that at least 240 clock hours are devoted to direct, face-to-face service to clients, and that of these 240 hours, a minimum 80 clock hours are
devoted to providing individual counseling services to clients and a minimum of 16 hours co-facilitating groups.. Furthermore, the agency agrees to offer
audio/video recording access or, in the absence of such recording, live observation or co-counseling. A maximum of 10 direct client contact hours (of the
minimum 240 required) can be obtained in telephone contact with clients.
5.
Provide opportunities for the Counselor Trainee/Intern to engage in the provision of clinical services, namely the diagnosis and treatment of mental
disorders. Such services include, but are not limited to, psychological testing, diagnostic assessment, providing appropriate treatment interventions, and
developing a comprehensive and individualized treatment plan for each client served. The provision of clinical services must include individual counseling (a
minimum of 80 clock hours is required) and co-facilitating group (a minimum of 16 hours is required). Other formats of clinical services include group,
couples, and family counseling, determined by the internship site supervisor and the student intern.
6.
If a Counselor Trainee/Intern is to engage in off-site services (e.g., home-based counseling, transportation of clients), proper training, safety measures (e.g.,
use of cell phone, obtaining immunization per Agency policy and at Agency expense, use of Agency vehicle only and only with adequate insurance coverage
provided by the Agency), and appropriate supervision will be provided by the Agency. If the Counselor Trainee/Intern will be expected to provide such
services, consultation with the Master’s Practicum and Internship Coordinator and/or Internship Instructor will be necessary prior to the commencement of
such services.
Revised April 2015
Page 6 of 23
7.
Provide appropriate working conditions and physical arrangements for the Counselor Trainee/Intern, such as desk space for completing paperwork, access
to a computer and a telephone, and office space in which to meet with clients privately. In addition, the Agency must provide a clinical instruction
environment that is conducive to modeling, demonstration, and training. The clinical instruction environment includes all of the following:
a.
settings for individual counseling with assured privacy and sufficient space for appropriate equipment (for example, video monitoring and
recording);
b. settings for small-group work with assured privacy and sufficient space for appropriate equipment;
c.
necessary and appropriate technologies that assist learning, such as audio, video, and telecommunications equipment;
d. settings with observational and/or other interactive supervision capabilities; and
e. procedures that ensure that the client’s confidentiality and legal rights are protected.
8.
Provide the minimum face-to-face supervisory requirements of one (1) hour for every 20 hours of overall service the student provides. Therefore, a 600hour internship would include a minimum of 30 hours of individual face-to-face supervision, with an additional hour for every 20 hours of internship activity
beyond the 600 clock hour minimum. It is strongly recommended that a set day/time for weekly supervision be established.
9.
Complete a review of weekly logs and activity reports, and complete the Counselor Trainee/Intern evaluation materials in a timely fashion and review these
materials with the Counselor Trainee/Intern.
10. Inform the University of Agency policies and procedures that are relevant to internship assignments and Counselor Trainee/Intern activities.
11. Maintain close communication with the University in relation to internship activities through available means such as internship site supervisor meetings,
correspondence with the Master’s Practicum and Internship Coordinator, on-site visits by the Internship Instructor, and telephone contacts.
12. Monitor Counselor Trainee/Intern performance and report to the University Internship Instructor and/or Master’s Practicum and Internship Coordinator
any difficulties in performance, ethics, or other internship related activities arise.
13. Allow the Counselor Trainee/Intern to attend weekly internship class sessions (usually held on Mondays, 7:20-10:0 p.m.) for the duration of his/her
internship experience (determined by the time period indicated on the first and last pages of this agreement).
Internship Student Responsibilities
1.
The student intern will be enrolled in the Clinical Mental Health Counseling Internship course for each semester internship is undertaken (typically 3 credit
hours for each of the two semesters internship is undertaken) and will attend in-person all classes/seminars for the Clinical Mental Health Counseling
Internship course for the entire length of the agreed upon internship experience (the internship class is usually held on Mondays, 7:20-10:0 p.m.).
Internship students will continue working at their internship site (e.g., meeting with clients) until the end of their last semester of internship specified in this
agreement, even if they complete the required minimum 600 hours prior to the conclusion of that academic semester.
2.
The student intern will complete a weekly log and activity report, obtain his/her internship site supervisor’s initials on each printed activity report, and will
submit the originals on a weekly basis to the Clinical Mental Health Counseling Internship Instructor, and copies to the internship site/clinical supervisor.
3.
The student intern will complete duties assigned and at hours scheduled at the internship site, according to the agreement established between the
student and agency representative. This includes fulfilling a minimum of 20 clock hours of internship activities per week, reporting directly to the internship
site/clinical supervisor regarding client issues during regularly scheduled individual supervision sessions, and meeting with the internship site/clinical
supervisor outside of regularly scheduled individual supervision sessions (e.g., in response to client crisis/emergency issues).
4.
The student intern will be expected to conduct himself or herself in a professional manner expected of all Counselor Trainees and Professional Counselors
throughout the entirety of the internship experience. This means up-holding and abiding by the American Counseling Association's (ACA; 2005) ACA Code of
Ethics [http://www.counseling.org], as well as the Code of Ethical Practice and Professional Conduct of the State of Ohio Counselor, Social Worker, and
Marriage and Family Therapist Board (Rule 4757-5-01 of the ORC) [http://www.cswmft.ohio.gov].
5.
The student intern is responsible for ensuring that all paperwork related to the internship experience is completed in a timely fashion (i.e., according to
deadlines specified in this Manual and in Internship class) and on file.
6.
The student intern will be certain the internship site and assigned site/clinical supervisor receive a copy of the University calendar, student handbook, and
this Internship Manual.
7.
The student intern will be certain that the Internship Site and Master’s Practicum and Internship Coordinator receive copies of the completed Internship
Agreement form and the Assigned Supervisor Qualifications form by June 15, if starting Fall semester; November 15, if starting Spring semester; or by April
15, if starting Summer term. The student will also be certain that the CES mid-internship evaluation form, CES final evaluation form, and the evaluation of
the internship (Site and University) are properly completed and placed in the student’s internship file.
8.
The student will purchase professional liability insurance and have proof of current coverage available throughout the internship experience.
9.
The student will be registered as a “Counselor Trainee” with the Ohio CSW&MFT Board for the entirety of internship.
Revised April 2015
Page 7 of 23
The signatures below indicate that each person understands the Internship requirements for the Clinical Mental Health Counseling Master’s degree Program at
Kent State University. The signatures also represent each person’s agreement to uphold his or her respective responsibilities outlined in this Internship
Agreement form.
The Clinical Mental Health Counseling Internship will take place (check one):

Fall _________ and Spring _________ (approx. 36 weeks total, including Fall final exam week, 4-week winter break, and Spring break)

Spring ________ and Summer ________ (approx. 31 weeks total, including Spring break, Spring final exam week, 4-week spring/summer intersession,
and 10 week summer term)

Summer ________ and Fall ________ (approx. 26 weeks total, including 10-week summer term, one week in-between summer term and start of Fall
semester)
Agency Representative
Agency Name, Address, and Telephone #:
Signed: _____________________________________
________________________________________
Printed: _____________________________________
________________________________________
Title: _______________________________________
________________________________________
Date: _______________________________________
(__________)______________________________
Student
Master’s Practicum and Internship Coordinator
Signed: ____________________________________
Signed: _________________________________
Printed: ____________________________________
Printed:_________________________________
Date: ______________________________________
Date:___________________________________
Revised April 2015
Page 8 of 23
KENT STATE UNIVERSITY
CLINICAL MENTAL HEALTH COUNSELING PROGRAM
INTERNSHIP IN CLINICAL MENTAL HEALTH COUNSELING
ASSIGNED SUPERVISOR QUALIFICATIONS FORM
Directions: Please type or print CLEARLY all requested information. This form needs to be completed at or about the time the Internship Agreement Form is
completed (i.e., by June 15, if starting Fall semester; November 15, if starting Spring semester; or April 15, if starting Summer term) and the original submitted to
the Master’s Practicum and Internship Coordinator.
Name of Clinical Mental Health Counseling Student Intern:
Name, Address, and Phone # (with area code) of assigned Internship Site Supervisor: (or attach business card)
Graduate Degree(s) of Internship Supervisor (include academic institution and date of earning degree(s)):
Certificate(s) and License(s) of Internship Supervisor (include accrediting body and date of expiration):
Internship will extend for _________ hours a week (minimum of 20 hours/week) for __________ weeks, totaling at least 600 clock hours of service, of which a
minimum of 240 clock hours are devoted to direct, face-to-face service to clients (80 of which are in individual client contact). Clinical services will include the
diagnosis and treatment of mental disorders. Minimum individual face-to-face supervision hours to be provided each week =1 hour of individual supervision for
every 20 work hours. It is strongly recommended that a set day/time for weekly individual supervision be established for the entirety of internship. The
Internship Site/Clinical Supervisor will assume full and direct legal responsibility for the welfare of all clients seen by the Student Intern.
* Please attach a brochure of the agency/service organization.
Internship Site/Clinical Supervisor’s Signature:
__________________________________________________________ Date: _____________
Printed Internship Site/Clinical Supervisor’s Name:
_____________________________________________________________________________
Agency Name:
_____________________________________________________________________________
Student Intern’s Signature:
__________________________________________________________ Date: _____________
Printed Student Intern’s Name:
_____________________________________________________________________________
Master’s Practicum & Internship Coordinator’s Signature:
__________________________________________________________ Date: _____________
Revised April 2015
Page 9 of 23
Week # _________________
KENT STATE UNIVERSITY
CLINICAL MENTAL HEALTH COUNSELING PROGRAM
INTERNSHIP IN CLINICAL MENTAL HEALTH COUNSELING
WEEKLY INTERN ACTIVITY REPORT & LOG
KENT STATE UNIVERSITY
COUNSELOR EDUCATION AND SUPERVISION PROGRAM
CLINICAL MENTAL HEALTH COUNSELING INTERNSHIP
WEEKLY INTERNSHIP LOG
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
Name: ______________________________________________________________________________ Week of:___________________ (month/day/year)
Agency Name:__________________________________________________ Site Supervisor:___________________________________________________
Activity
Total Week
Total to Date
Direct Service (face-to-face counseling that may include crisis intervention, test administration, etc.)
Individual
0
Group
0
Family or couple
0
0
*Other (describe below)
Total Direct Service
0
0
Non-Direct Service
On-Site Supervision
Individual supervision
0
Group supervision
0
Subtotal for Supervision
0
0
Staff meetings
0
In-service training, workshop attendance
0
Documentation
0
Internship Class (2.5 hrs)
0
Contact with related agencies
0
0
**Other (describe below)
Total Non-Direct Service
GRAND TOTALS
0
0
0
0
Internship Instructor Signature: _______________________________________________________________________________
Date ________________
* "Other" Direct Service:
** "Other" Non-Direct Service:
Revised April 2015
Page 10 of 23
II. WEEKLY ACTIVITY REPORT: Describe your assignment within the agency this week by responding to the following questions. Please be as specific as you can,
citing appropriate and helpful examples.
A. What specifically am I expected to do this week?
B. In what ways is my assignment different than at the time of the last report?
C. Mention specific learning or practice objectives that you and/or your supervisor have developed for you for this week.
D. Delineate new areas of growth and development during this report period (please be specific). How will you apply these areas in the near future?
E. Are there tasks or assignments which you would like to have added to your workload?
Revised April 2015
Page 11 of 23
F. Describe any major practice problems you feel you are having.
G. Assess your own performance during this report period. Please provide specific examples.
III. Internship Concerns:
Indicate any internship-related problems that you are experiencing. What steps have you already taken to resolve the problem? Is your site supervisor aware of
this problem?
Please indicate any matter that you feel requires the assistance of the internship instructor.
IV. Internship Site/Clinical Supervisor’s Initials and Date: _______________________

Yes, I have reviewed this week’s activity report and log completed by the Clinical Mental Health Counseling Student Intern.

I request a phone call or a meeting with the KSU Clinical Mental Health Counseling Internship Instructor or Master’s Practicum and Internship
Coordinator to discuss questions and/or concerns I have about this student’s internship.
Revised April 2015
Page 12 of 23
CMHC Internship
Skill Evaluation Form
Student Name: ______________________________________________________________________________________ Banner ID: _______________________
Person Completing Evaluation: __________________________________________________________________ Title: ___________________________________
Instructions:

Clearly write your score in the far right column titled “Score”. Place and “X” in the “Score” column if the standard was not observed.

When this form is completed, turn it into the CES secretary for data entry.

Items scored as 4 -5 are considered acceptable. If any items are scored as 1 or 2, the instructor should discuss specific concerns with the student and
ways the student can improve.
Standard
1.D. Self-care
strategies
appropriate to the
counselor role
5.B. Counselor
characteristics and
behaviors that
influence helping
processes
5.b.1. Empathy
5.b.2. Unconditional
Positive Regard
5.b.3. Congruence
5.C. Essential
interviewing and
counseling skills
5.c.1. Establishing
Relationships
1
The student
cannot verbalize
a need for selfcare
2
The student cannot
verbalize strategies
for self-care
3
The student can verbalize
self-care strategies but
does not or cannot
implement the strategies
4
The student integrates
self-care strategies but
not continually
5
The student continually
integrates and adapts
new self-care strategies
The verbal and
behavioral
expression by
the student does
not attend to
and detract
significantly from
the client
When the student
responds they do so
in such a way that it
subtracts
noticeable affect
from the
communications of
the client
The expressions of the
student are essentially
interchangeable with
those of the client in that
they express the same
affect and meaning
The responses of the
student add noticeably
to the client in such a
way to express feeling
levels deeper then
those expressed by the
client
Does not show
ANY ability to
suspend
judgmental
thinking, value
clients as
individuals, and
think positively
about them
Is incongruent
among, self,
thoughts, and
actions
Shows one of three
of the following
qualities; suspend
judgmental
thinking, value
clients as
individuals, and
think positively
about them
Is aware of
incongruence
among self,
thoughts, and
actions
Shows two of three of
the following qualities;
suspend judgmental
thinking, value clients as
individuals, and think
positively about them
Shows three of the
following qualities (but
not consistently across
clients); suspend
judgmental thinking,
value clients as
individuals, and think
positively about them
The student’s responses
add significantly to the
feeling and meaning of
the client expression
and when the client is in
ongoing deep selfexploration, the student
remains immediate to
that experience
Student is ABLE to show
consistently across
clients the ability to
suspend judgmental
thinking, value clients
as individuals, and think
positively about them
Begins to take action in
client sessions to be
more congruent in their
experience of the client
Takes regular action in
client sessions to be
more congruent in their
experience of the client
Demonstrates
consistent congruence
among self, thoughts,
and actions
Shows no
pattern for
establishing a
counseling
relationship
Starts counseling
relationship with
introduction but
w/o structured
ethical introduction
(professional
disclosure, fees,
cancellation,
orientation,
confidentiality,
informed consent,
questions)
Starts counseling
relationship with
introduction but misses
many components of a
structured ethical
introduction
(professional disclosure,
fees, cancellation,
orientation,
confidentiality, informed
consent, questions)
Starts counseling
relationship with
introduction but misses
a few components of a
structured ethical
introduction
(professional disclosure,
fees, cancellation,
orientation,
confidentiality,
informed consent,
questions)
Demonstrates a
complete process of
establishing a
counseling relationship
with a complete ethical
introduction
(professional disclosure,
fees, cancellation,
orientation,
confidentiality,
informed consent,
questions)
Revised April 2015
Page 13 of 23
Score
Standard
5.C. Essential
interviewing and
counseling skills
5.c.1. Establishing
Relationships
1
Shows no
pattern for
establishing a
counseling
relationship
5.c.2. Attending
Does not
practice
attending
behavior
5.c.3. Questions
Asks few
questions or the
questions do not
appear to follow
any logical
pattern; does
not verbally
track client
Makes no use of
observation skills
5.c.4. Observation
Skills
5.c.5. Encouraging
Makes no use of
encouraging
skills
5.c.6. Paraphrasing
Paraphrases w/o
intentionally
using any of the
four dimensions;
sentence stem,
keywords,
essence, and
check-out
Summarizes w/o
intentionally
using any of the
four dimensions;
sentence stem,
keywords,
essence, and
check-out
Makes no use of
skills to end a
session
5.c.7. Summarizing
5.c.8. Ending a
Session
Revised April 2015
2
3
4
5
Starts counseling
relationship with
introduction but
w/o structured
ethical introduction
(professional
disclosure, fees,
cancellation,
orientation,
confidentiality,
informed consent,
questions)
Shows some
inaccurate and
inconsistent
attending
behaviors; visual
contact, verbal
tracking, vocal
qualities, body
language
Uses unintentional
pattern of
questions and does
not follow logical
pattern of client
verbal tracking
Starts counseling
relationship with
introduction but misses
many components of a
structured ethical
introduction
(professional disclosure,
fees, cancellation,
orientation,
confidentiality, informed
consent, questions)
Starts counseling
relationship with
introduction but misses
a few components of a
structured ethical
introduction
(professional disclosure,
fees, cancellation,
orientation,
confidentiality,
informed consent,
questions)
Attending behavior is
mostly consistent and
accurate; visual contact,
verbal tracking, vocal
qualities, body language
Demonstrates a
complete process of
establishing a
counseling relationship
with a complete ethical
introduction
(professional disclosure,
fees, cancellation,
orientation,
confidentiality,
informed consent,
questions)
Attending behavior is
accurate and complete
Selects open and closed
ended questions
appropriately; does not
follow client verbal
tracking
Selects open and closed
ended questions
appropriately and
mostly tracks client
Include questions
appropriately; using
closed and open ended
questions and closely
follows verbal tracking
Demonstrates some
observational skills
but does not show
immediacy in
response to the
client
Rarely uses
encouraging
comments to client
Uses observation skills
but rarely uses
immediacy in presenting
them to the client
Uses appropriate
observation skills with
occasional immediacy
Uses appropriate
observation skills and is
able to show immediacy
with them when
working with a client
Uses primarily non-verbal
or minimal encouragers
with client
Paraphrases and
misses key points in
client verbal
tracking and
components of the
four dimensions
Paraphrases getting key
verbal tracking but
missing check-out and
use of key words
Uses a range of
encouragers (head
nods, uh-huh,
keywords, and short
statements with client)
Paraphrases w/ checkout but lacks full breath
of the client story
Intentionally uses a
range of
appropriate/timely
encouraging skills with
a client
Paraphrases using
sentence stem,
keywords, essence, and
check-out
Summarizes and
misses key points in
client verbal
tracking and
components of the
four dimensions
Summarizes getting key
verbal tracking but
missing check-out and
use of key words
Summarizes w/ checkout but lacks full breath
of the client story
Summarizes using
sentence stem,
keywords, essence, and
check-out
Summarizes end of
session; there is
little process other
than to explain
parts of what
happened in the
session; student
assigns homework
w/o client
involvement
Summarizes end of
session; includes checkout with client. student
may or may not assign
homework but w/o client
involvement
Summarizes w/
checkout, may miss one
of the following
components; client
strengths and
continuity plan for next
session. May or may not
assign homework and
does so with client
involvement
Does complete
summary, check-out,
strengths, and
continuity plan with
client as part of
summary
Attending behavior is
accurate but
inconsistent; visual
contact, verbal tracking,
vocal qualities, body
language
Page 14 of 23
Score
Standard
5.c.9. Reflection of
Feelings
B.1. Demonstrates
the ability to apply
and adhere to ethical
and legal standards
in clinical mental
health counseling.
B.1.a. Confidentiality
B.1.b. Boundaries
B.1.c. Record
Keeping
B.1.d. Areas of
Competence
B.1.e. Counseling
Minors
D.1. Uses the
principles and
practices of dx, tx,
referral, and
prevention of mental
and emotional
disorders to initiate,
maintain, and
terminate
counseling.
D.1.a. Appropriately
uses the principles
and practices of
diagnosis to initiate
counseling
D.1.b. Appropriately
uses the principles
and practices of
diagnosis to
maintain counseling
D.1.c. Appropriately
uses the principles
and practices of
diagnosis to
terminate counseling
D.1.d. Appropriately
uses the principles
and practices of
treatment to initiate
counseling
1
Does not reflect
feelings
Inappropriately
reveals private
information to
select others
Has serious
boundary
problems with
clients
Appropriate
records are not
kept
2
Attempts to reflect
feelings but does so
inaccurately
3
Reflects feelings
inconsistently with
varying levels of
appropriateness
4
Consistently reflects
feelings appropriately
5
Consistently reflects
feelings appropriately
and integrates it into
case conceptualization
Always maintains
appropriate
confidentiality
Has minor boundary
problems with clients
Has no boundary
problems with clients
Records are kept
infrequently,
inaccurately and
sloppily
Often counsels
clients outside
many areas of
expected
developmental
level
Records are kept well
except for lapses in two
areas (e.g., timely and
neatly)
Sometimes counsels
clients outside a few
areas of expected
developmental level
Records are kept well
except for lapses in one
area (e.g., timely and
neatly)
Rarely counsels clients
outside any areas of
expected
developmental level
Records are kept
accurately and neatly at
all times.
Often disregards
client development
and fails to inform
care givers
appropriately
Sometimes disregards
client development or
fails to inform care givers
appropriately
Rarely disregards client
development or fails to
inform care givers
appropriately
Never disregards client
development or fails to
inform care givers
appropriately
Never
Rarely
Sometimes
Always
Always and can
integrate into
treatment planning
Never
Rarely
Sometimes
Always
Always and can
integrate into
treatment planning
Never
Rarely
Sometimes
Always
Always and can
integrate into
treatment planning
Never
Rarely
Sometimes
Always
Always and can
integrate into
treatment planning
Consistently
counsels clients
outside many
areas of
expected
developmental
level
Always
disregards client
development
and fails to
inform care
givers
appropriately
Revised April 2015
Never counsels clients
outside any areas of
expected
developmental level
Page 15 of 23
Score
Standard
D.1.c. Appropriately uses the
principles and practices of diagnosis
to terminate counseling
D.1.d. Appropriately uses the
principles and practices of treatment
to initiate counseling
D.1.e. Appropriately uses the
principles and practices of treatment
to maintain counseling
D.1.f. Appropriately uses the
principles and practices of treatment
to terminate counseling
D.1.g. Appropriately uses the
principles and practices of referring
to initiate counseling
D.1.h. Appropriately uses the
principles and practices of referring
to maintain counseling
D.1.i. Appropriately uses the
principles and practices of referring
to terminate counseling
D.1.j. Appropriately uses the
principles and practices of
prevention to initiate counseling
D.1.k. Appropriately uses the
principles and practices of
prevention to maintain counseling
D.1.l. Appropriately uses the
principles and practices of
prevention to terminate counseling
D.2. Applies multicultural
competencies to clinical mental
health counseling involving case
conceptualization, diagnosis,
treatment, referral, and prevention
of mental and emotional disorders.
D.3. Promotes optimal human
development, wellness, and mental
health through prevention,
education, and advocacy activities.
D.4. Applies effective strategies to
promote client understanding of and
access to a variety of community
resources.
D.5. Demonstrates appropriate use
of culturally responsive individual,
couple, family, group, and systems
modalities for initiating, maintaining,
and terminating counseling.
D.5.a. Demonstrates appropriate use
of culturally responsive individual
modalities
D.5.b. Demonstrates appropriate use
of culturally responsive couple
modalities
D.5.c. Demonstrates appropriate use
of culturally responsive family
modalities
D.5.d. Demonstrates appropriate use
of culturally responsive group
modalities
D.5.e. Demonstrates appropriate use
of culturally responsive systems
modalities
Revised April 2015
1
Never
Rarely
2
3
Sometimes
Always
4
Never
Rarely
Sometimes
Always
Never
Rarely
Sometimes
Always
Never
Rarely
Sometimes
Always
Never
Rarely
Sometimes
Always
Never
Rarely
Sometimes
Always
Never
Rarely
Sometimes
Always
Never
Rarely
Sometimes
Always
Never
Rarely
Sometimes
Always
Never
Rarely
Sometimes
Always
Never
Rarely
Sometimes
Often
5
Always and can
integrate into
treatment planning
Always and can
integrate into
treatment planning
Always and can
integrate into
treatment planning
Always and can
integrate into
treatment planning
Always and can
integrate into
treatment planning
Always and can
integrate into
treatment planning
Always and can
integrate into
treatment planning
Always and can
integrate into
treatment planning
Always and can
integrate into
treatment planning
Always and can
integrate into
treatment planning
Always
Never
Rarely
Sometimes
Often
Always
Does not
use nor
understand
strategies
Rarely uses or often
misuses strategies
Sometimes uses or
sometimes misuses
strategies
Usually uses
strategies
appropriately
Always uses
strategies
appropriately
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Page 16 of 23
Score
Standard
D.6. Demonstrates the ability to
use procedures for assessing
and managing suicide risk.
D.7. Applies current recordkeeping standards related to
clinical mental health
counseling.
D.7.a. Timely in accordance to
site guidelines
D.7.b. Record Security
D.7.c. Accuracy
D.7.d. Thoroughness
D.7.e. Conciseness
D.7.f. Makes documented links
to treatment plan
D.8. Provides appropriate
counseling strategies when
working with clients with
addiction and co-occurring
disorders.
D.9. Demonstrates the ability to
recognize his or her own
limitations as a clinical mental
health counselor and to seek
supervision or refer clients
when appropriate.
D.9.a. Recognition of
Limitations
D.9.b. Seeks supervision when
necessary
D.9.c. Makes Appropriate
Referrals
F.1. Maintains information
regarding community resources
to make appropriate referrals.
H.2. Demonstrates skill in
conducting an intake interview,
a mental status evaluation, a
biopsychosocial history, a
mental health history, and a
psychological assessment for
treatment planning and
caseload management.
H.2.a. Skill in conducting an
intake interview
H.2.b. Skill in conducting a
mental status evaluation
Revised April 2015
1
Does not
recognize signs
of suicide
2
Recognizes
signs of suicide
but does not or
does not
adequately
assess or
manage risk but
seeks
supervision
3
Assesses or
manages suicide
risk in a basic or
shallow manner
(e.g., PIMP model)
4
Provides a thorough /
comprehensive assessment
of suicide risk (e.g., SIMPLE
STEPS model);
comprehensively manages
suicide risk with short and
long term goals for
treatment – though is
apprehensive and/or needs
great amounts of
supervision
5
Provides a thorough
/ comprehensive
assessment of
suicide risk (e.g.,
SIMPLE STEPS
model);
comprehensively
manages suicide risk
with short and long
term goals for
treatment
Never
Rarely
Sometimes
Often
Always
Never
Never
Never
Never
Never
Rarely
Rarely
Rarely
Rarely
Rarely
Sometimes
Sometimes
Sometimes
Sometimes
Sometimes
Often
Often
Often
Often
Often
Always
Always
Always
Always
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never make
referrals
Does not
recognize when
referrals are
needed, but
makes them
after prompting
Usually recognizes
the need for
referrals and
makes them after
prompting
Usually recognizes the need
for referrals and makes
them appropriately
Always recognizes
the need for referrals
and makes them
appropriately
Does not
understand
how to
conduct,
interpret, or
integrate an
intake with
treatment
Does not
understand
how to
conduct,
interpret, or
integrate a MSE
with treatment
Has basic
knowledge of
how to conduct
an intake but
has difficulty in
the skill of
conducting an
intake
Has basic
knowledge of
how to conduct
a MSE but has
difficulty in the
skill of
conducting a
the MSE
Has basic
knowledge and
skill if effectively
conducting an
intake
Can effectively conduct an
intake and has a basic
knowledge of how to
conceptualize the intake
into treatment
Can effectively
conduct an intake,
utilize information
from the intake into
ongoing diagnosis
and treatment
planning
Has basic
knowledge and
skill if effectively
conducting an
MSE
Can effectively conduct an
MSE and has a basic
knowledge of how to
conceptualize the results of
the MSE into treatment
Can effectively
conduct a MSE,
utilize information
from the MSE into
ongoing diagnosis
and treatment
planning
Page 17 of 23
Score
Standard
F.1. Maintains information
regarding community
resources to make
appropriate referrals.
H.2. Demonstrates skill in
conducting an intake
interview, a mental status
evaluation, a biopsychosocial
history, a mental health
history, and a psychological
assessment for treatment
planning and caseload
management.
H.2.a. Skill in conducting an
intake interview
H.2.b. Skill in conducting a
mental status evaluation
H.2.c. Skill in conducting a
biopsychosocial history
H.2.d. Skill in conducting a
mental health history
H.2.e. Skill in conducting
psychological assessment(s)
H.3. Screens for addiction,
aggression, and danger to
self and/or others, as well as
co-occurring mental
disorders.
H.3.a. Appropriately Screens
for Addiction
H.3.b. Appropriately Screens
for Aggression
Revised April 2015
1
Never make
referrals
2
Does not
recognize when
referrals are
needed, but
makes them after
prompting
3
Usually recognizes
the need for
referrals and
makes them after
prompting
4
Usually recognizes the need
for referrals and makes
them appropriately
5
Always recognizes
the need for referrals
and makes them
appropriately
Does not
understand
how to
conduct,
interpret, or
integrate an
intake with
treatment
Does not
understand
how to
conduct,
interpret, or
integrate a MSE
with treatment
Does not
understand
how to
conduct,
interpret, or
integrate a BPS
Hx with
treatment
Does not
understand
how to
conduct,
interpret, or
integrate a MH
Hx with
treatment
Does not
understand
how to
conduct,
interpret, or
integrate a
psychological
assessment
with treatment
Has basic
knowledge of how
to conduct an
intake but has
difficulty in the
skill of conducting
an intake
Has basic
knowledge and
skill if effectively
conducting an
intake
Can effectively conduct an
intake and has a basic
knowledge of how to
conceptualize the intake
into treatment
Can effectively
conduct an intake,
utilize information
from the intake into
ongoing diagnosis
and treatment
planning
Has basic
knowledge of how
to conduct a MSE
but has difficulty
in the skill of
conducting a the
MSE
Has basic
knowledge of how
to conduct a BPS
Hx but has
difficulty in the
skill of conducting
a the BPS Hx
Has basic
knowledge and
skill if effectively
conducting an
MSE
Can effectively conduct an
MSE and has a basic
knowledge of how to
conceptualize the results of
the MSE into treatment
Has basic
knowledge and
skill if effectively
conducting an BPS
Hx
Can effectively conduct an
BPS Hx and has a basic
knowledge of how to
conceptualize the results of
the BPS Hx into treatment
Can effectively
conduct a MSE,
utilize information
from the MSE into
ongoing diagnosis
and treatment
planning
Can effectively
conduct a BPS Hx,
utilize information
from the BPS Hx into
ongoing diagnosis
and treatment
planning
Has basic
knowledge of how
to conduct a MH
Hx but has
difficulty in the
skill of conducting
a the MH Hx
Has basic
knowledge and
skill if effectively
conducting an MH
Hx
Can effectively conduct an
MH Hx and has a basic
knowledge of how to
conceptualize the results of
the MH Hx into treatment
Can effectively
conduct a BPS Hx,
utilize information
from the MH Hx into
ongoing diagnosis
and treatment
planning
Has basic
knowledge of how
to select,
administer, score,
and use a
psychological
assessment in
treatment along
with integrating
results into
treatment
Can effectively
select, administer,
score, and use a
psychological
assessment in
treatment along
with integrating
results into
treatment with
extensive
supervision
Can effectively select,
administer, score, and use a
psychological assessment in
treatment along with
integrating results into
treatment with minimal
supervision
Can effectively
select, administer,
score, and use a
psychological
assessment in
treatment along with
integrating results
into treatment
independently
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Page 18 of 23
Score
Standard
H.3. Screens for addiction,
aggression, and danger to
self and/or others, as well as
co-occurring mental
disorders.
H.3.a. Appropriately Screens
for Addiction
H.3.b. Appropriately Screens
for Aggression
H.3.c. Appropriately Screens
for Danger to Self
H.3.d. Appropriately Screens
for Danger to Others
H.3.e. Appropriately Screens
for Co-Occurring Disorders
J.1. Applies relevant research
findings to inform the
practice of clinical mental
health counseling.
L.1. Demonstrates
appropriate use of diagnostic
tools, including the current
edition of the DSM, to
describe the symptoms and
clinical presentation of
clients with mental and
emotional impairments.
L.2. Is able to conceptualize
an accurate multi-axial
diagnosis of disorders
presented by a client and
discuss the differential
diagnosis with collaborating
professionals.
CES 1. Ability to structure a
session intentionally
CES 2. Integrates multiple
micro-skills fluidly
1
2
3
4
5
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Does not
participate in
this activity
Looks at research
but does not
understand it
Uses research to work with
clients with minimal
assistance
Uses research to
work with clients
independently
Never
Rarely
Looks at research
and tries to use it
with clients
though needs
extensive
assistance
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Score
Provide 3-4 specific recommendations for continued professional growth and development in the space below (or attach a separate sheet):
For Site Supervisors completing evaluation on Internship I students (Check One):
______ Based on the above standards, this student has met the skills requirement for an Internship I student.
______ Based on the above standards, this student has not met the skills requirement for an Internship I student.
For Site Supervisors completing evaluation on Internship II students (Check One):
______ Based on the above standards, this student has met the skills requirement for an Internship II student.
______ Based on the above standards, this student has not met the skills requirement for an Internship II student.
Student’s Signature:
__________________________________________________________ Date: _____________
Site Supervisor’s Signature:
__________________________________________________________ Date: _____________
Master’s Practicum & Internship Coordinator’s Signature:
__________________________________________________________ Date: _____________
Revised April 2015
Page 19 of 23
CMHC Internship Professional
Behavior Evaluation Form
Student Name: ______________________________________________________________________________________ Banner ID: _______________________
Person Completing Evaluation: __________________________________________________________________________ Title: ___________________________
Instructions:

This form is to be completed at the end of Internship I and Internship II.

When this form is completed, turn it into the CES secretary for data entry.

Please place a check in the appropriate box.

Professional behavior is expected of all CES students during class, while working in the Counseling and Human Development Center, and while
working with other students on class assignments. If a students professional behavior is deemed as questionable, programmatic remediation may
need to occur. If any item is marked as 1-3, please inform the CES Master’s Programs Coordinator (Dr. Guillot-Miller) and remediation will be
determined. In Section B, if any of the Professional Behaviors are not “always” done (meaning NEVER not done), please inform the CES Master’s
Programs Coordinator (Dr. Guillot-Miller) and remediation will be determined. However, there are multiple levels of severity of professional behavior
and remediation could occur even if there was only once correction.

All scores contribute to the overall grade in this course.
Section A: Professional Behavior
Never Occurs
After Multiple
Corrections
1
Occurs After
Multiple
Corrections
2
Occurs
After Few
Corrections
3
Occurs
After One
Correction
4
Always
occurs
Not
Applicable
5
X
Dresses Appropriately
Is on time for appointments
Is on time to site
Interacts with colleagues in a professional manner
Interacts with office staff in a professional manner
Has professional demeanor on telephone with
clients/parents
Completes record keeping in a timely manner
Treats clients with respect in waiting areas
Arrives at site on agreed dates and times
Calls to report inability to come to site in a timely
and professional manner
Arrives prepared for supervision
Assists colleagues when appropriate and needed
Follows site guidelines / policies
Accepts feedback
Arrives prepared for client sessions
Takes initiative on projects when appropriate
Maintains proper personal hygiene
Section B: Professional Behavior
Discusses client cases only in appropriate settings
Maintains client confidentiality through proper record handling
Is respectful of all clients regardless of any differences
Complies with supervisor directions
Seeks supervision when needed
Serious Concern
Always
For Site Supervisors completing evaluation on Internship I students (Check One):
______ Based on the above standards, this student has met the skills requirement for an Internship I student.
______ Based on the above standards, this student has not met the skills requirement for an Internship I student.
For Site Supervisors completing evaluation on Internship II students (Check One):
______ Based on the above standards, this student has met the skills requirement for an Internship II student.
______ Based on the above standards, this student has not met the skills requirement for an Internship II student.
Student Signature:
__________________________________________________________ Date: _____________
Site Supervisor’s Signature:
__________________________________________________________ Date: _____________
Master’s Practicum & Internship Coordinator’s Signature:
__________________________________________________________ Date: _____________
Content in this evaluation taken from Ivey & Ivey (2008); Carkhuff, (1972); and Stoltenberg, McNeill, & Delworth (1998).
Revised April 2015
Page 20 of 23
KENT STATE UNIVERSITY
CLINICAL MENTAL HEALTH COUNSELING PROGRAM
INTERN’S ASSESSMENT OF THE INTERNSHIP
Student Name: ______________________________________________________________________________________ Banner ID: _______________________
Person Completing Evaluation: __________________________________________________________________ Title: ___________________________________
This evaluation is for the purpose of providing feedback to the Site/Clinical Supervisor, the Agency, and the University regarding student perceptions of the
internship experience. This instrument is designed as a guide to facilitate the sharing of the most significant perceptions and impressions that occur throughout
the internship experience. As a student counselor and a beginning professional, you are urged to complete this instrument completely and honestly. You should
already have begun this kind of critical sharing with your site/clinical supervisor, others in the Agency, and your faculty Internship Instructor. Your responses can
aid your own professional development, and your assessment will significantly help the Agency and the University be even more responsive to student needs.
1. Complete the rating form as follows (circle appropriate responses for each item):
5
-Indicates complete satisfaction or an extremely positive response with the item. Where
behavior is referred to, the behavior was always present when appropriate.
4
-Moderate satisfaction: Desired behavior or condition was frequently present.
3
-Somewhat satisfied: Desired behavior or condition was sometimes absent.
2
-Somewhat dissatisfied: Desired behavior or condition was often absent.
1
-Extremely dissatisfied: Desired behavior or condition was seldom present.
X
-It is not possible to assess this item.
2. Provide written comments regarding those items for which you have a special concern.
I. The Internship Process
1
2
3
4
5
6
Was there sufficient information about the internship prior to actually starting the experience?
Did you feel the kind of setting provided was appropriate to your needs and interests?
Was orientation at the agency sufficient when the internship began?
Overall, did the internship instructor meet his/her responsibilities for your internship experience?
During the internship experience, did you feel that you were treated as an individual with respect for your own
special circumstances?
Was the agency adequately prepared for your arrival?
5
5
5
5
4
4
4
4
3
3
3
3
2
2
2
2
1
1
1
1
X
X
X
X
5
4
3
2
1
X
5
4
3
2
1
X
5
5
5
4
4
4
3
3
3
2
2
2
1
1
1
X
X
X
5
5
5
4
4
4
3
3
3
2
2
2
1
1
1
X
X
X
5
4
3
2
1
X
5
5
4
4
3
3
2
2
1
1
X
X
5
4
3
2
1
X
5
4
3
2
1
X
II. The Agency Setting
1
2
3
Was interaction with other counselors and related disciplines sufficient?
Did the agency provide you with adequate working conditions?
Overall, did you feel the agency attached sufficient importance to your internship experience?
III. Professional Development
1
2
3
4
5
6
7
8
Did the experience acquaint you with the operation of a community service agency?
Did the internship experience improve your capacity to work with people in a helping relationship?
Did the placement acquaint you with resources available in the community?
Did the internship significantly increase your knowledge of specific problems in the community, e.g., poverty,
mental illness, aging, alcoholism and other addictions, and so on?
Rate your general level of satisfaction with the amount and kind of clinical practice activity you were assigned.
Was there a sufficient diversity of learning activities?
Were there opportunities to be part of the “larger agency” such as by attending staff meetings, in-service
training, and so on?
Did this agency experience help you understand and use professional record keeping procedures?
Revised April 2015
Page 21 of 23
IV. Direct Supervision
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Did your supervisor stimulate professional counselor identity?
Did your supervisor help you feel accepted and respected as a person?
Did your supervisor help in demonstrating professional relationships with staff members at the site?
Did your supervisor meet with you for supervision at established times and for the agreed upon time?
Did your supervisor assist in conceptualizing your clients?
Did your supervisor help clarify objectives for your counseling sessions?
Did your supervisor help organize relevant case data in planning procedures for working with your clients?
Did your supervisor guide you in generating your own solutions to problems faced with clients?
Did your supervisor provide you with useful feedback regarding your counseling skills?
Did your supervisor help you focus on how your personal style influenced clients?
Did your supervisor adequately reinforce the development of your strengths and capabilities?
Did your supervisor help you use appraisal instruments constructively in counseling?
Was your supervisor helpful in critiquing your report writing?
Did your supervisor allow and encourage you to evaluate your work with clients?
5
5
5
5
5
5
5
5
5
5
5
5
5
5
4
4
4
4
4
4
4
4
4
4
4
4
4
4
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Optional: Provide additional comments in the space below (or attach a separate sheet):
The Site/Clinical Supervisor and Intern have been involved in an evaluation process that they have discussed with one another. Significant disagreement on the
part of the Intern or Site/Clinical Supervisor regarding this assessment should be noted in writing and forwarded to the Internship Instructor as an addendum to
this form.
Student’s Signature:
__________________________________________________________ Date: _____________
Evaluator’s Signature:
__________________________________________________________ Date: _____________
Instructor’s Signature:
__________________________________________________________ Date: _____________
Master’s Practicum & Internship Coordinator’s Signature:
__________________________________________________________ Date: _____________
Revised April 2015
Page 22 of 23
KENT STATE UNIVERSITY
CLINICAL MENTAL HEALTH COUNSELING PROGRAM
INTERNSHIP COMPLETION FORM
The following signatures indicate that_____________________________________________________________________________________________________
(Name of Student Intern)
satisfactorily fulfilled the expectations of the internship experience and met all requirements of the Clinical Mental Health Counseling Master’s degree internship.
Site Name and Address:________________________________________________________________________________________________________________
Total
Individual Client Contact Hours
Small Group Contact Hours
Group Client Contact Hours
Couple/Family Contact Hours
Other Contact Hours
Total # of Direct Client Contact Hours (Ind. & Group Combined + and Couple/Family Contact Hours)
Individual Supervision Hours
Group Supervision Hours (On-Site Supervision)
Internship Class (2.5 hrs.)
Total # of Supervision Hours (Ind. & Group Combined)
Other Non-Direct Hours
Total (All Client Contact, Supervision Combined, & Non-Direct)
Student (Print):
__________________________________________________________
Student Signature:
__________________________________________________________ Date: _____________
Site-Supervisor (Print):
__________________________________________________________
Site-Supervisor’s Signature:
__________________________________________________________ Date: _____________
Instructor (Print):
__________________________________________________________
Instructor’s Signature:
__________________________________________________________ Date: _____________
Master’s Practicum & Internship
Coordinator’s Signature:
__________________________________________________________ Date: _____________
Revised April 2015
Page 23 of 23