COUN 671
COUNSELING
INTERNSHIP
HANDBOOK
Summer 2012
TABLE OF CONTENTS
Introduction and State Requirements
p. 2
Sample Syllabus
pp. 3-6
Introduction Letter to Supervisors
p. 7
Procedures for Obtaining Internship Approval
p. 8
State of Ohio Professional Counselor Trainer Initial Application
pp. 9-11
Sample OCSWMFTB Internship Approval Letter
p. 13
Expectations for Xavier Interns
p. 14
Xavier University Affiliation Agreement and Instructions
pp. 15-17
Internship Log Form
pp. 18-26
Field Project Information
p. 27
Field Site Project Proposal Form
p. 28
Instructions for Extending Internship
p. 29
Extension Letter for OCSWMFTB
p. 30
Extension Request Form from OCSWMFTB
p.31-32
Incomplete Internship Form
p. 33
Student Evaluation Procedures
p. 34
Xavier University Interim Evaluation Form
p. 35
State of Ohio Internship Supervisor Evaluation Rating Form
pp. 36-39
Confidential Internship Site Evaluation Form
p. 40
1
XAVIER
UNIVERSITY
This booklet contains important information and the required forms necessary for you to successfully begin,
register, and verify the completion of your counseling internship. We recommend you read each item
thoroughly to help you avoid confusion in determining how the internship is approved and conducted.
To gain approval to begin your internship experience, all forms must be completed and returned to the
Clinical Coordinator. We also strongly recommend that you keep copies of all forms filed with Xavier
and/or the Ohio Counselor Board.
Best wishes for a successful internship experience!
INTERNSHIP INFORMATION
Students must have successfully completed COUN 669 and 773 (Counseling Pre-Practicum and Practicum),
before taking COUN 671.
OVERVIEW
The Ohio Counselor and Social Worker Board requires that a minimum of 600 clock hours of supervised
clinical counseling experience in an on-site setting be completed as part of the student’s Masters program.
The Xavier program is designed to help students meet this requirement by offering COUN 671. This
Counseling Internship is for 4 semester hours and requires a minimum of 600 clock hours of internship
activities.
Of this 600-clock hour total, the following requirements must be met:

240 of the 600 hours must be in direct service counseling activities with individuals and/or groups.

200 of the 600 hours must involve supervised activities in the area of diagnosis and treatment of
mental and emotional disorders.

Face-to-face meetings with the on-site supervisor must occur at a minimum ratio of one clock hour for
every 20-clock hours of intern activities.

Supervisors must possess a Professional Clinical Counseling (PCC) license. In addition, these
individuals must also possess a “Supervising Counselor” designation approved by the Ohio Board.

Internships must be pre-approved by the Xavier University Counseling Program Clinical Coordinator
and the Ohio Counselor Board.
While it is the student’s responsibility to procure an appropriate internship placement, the clinical
coordinator maintains a listing of possible internship sites for reference.

PROCEDURES
1. Students should contact the Xavier University Counseling Program Clinical Coordinator for a Counseling
Internship Packet. This packet contains the necessary information and forms required to approve and begin
your internship. It is recommended that students obtain this packet the semester prior to the anticipated
start of the internship.
2. After the completion of all forms and receiving the necessary approvals, students may begin to log
internship hours.
3. Once all approvals are granted (via CSSWMFT Board), students who are actively involved and registered
through Xavier University may refer to themselves as a “Counselor Trainee.”
2
SAMPLE
XAVIER UNIVERSITY
COURSE TITLE:
SEMESTER:
COURSE NUMBER:
CREDIT HOURS:
DAY & TIME:
LOCATION OF CLASS:
Counseling Internship
Fall 2004
COUN 671-01
4
Monday 4:15 p.m. – 6:45 p.m.
Joseph 312
INSTRUCTOR:
Dr. Rhonda L. Norman, LPCC, CCDC III-E
OFFICE LOCATION/PHONE: Hailstones 215 – 745-3450
E-MAIL ADDRESS:
norman@xavier.edu
OFFICE HOURS:
Monday and Wednesday 2:00 – 4:00pm and by appointment
COURSE DESCRIPTION:
This experiential course is designed as an integrative field placement. Students are expected
to engage in on-site counseling program activities that allow application of the Community
Counseling program curriculum content under the direction of an approved site supervisor
and Xavier faculty. The topics covered during the semester reflect those identified for the
Clinical Internship CACREP core area.
COURSE OBJECTIVES:
As a result of participating in this course students will:
 Understand the professional role of a community counselor and how the role
interfaces with their internship site.
 Understand and integrate multicultural issues such as race, culture, sexual
orientation and class into the clinical internship practice.
 Be able to describe the characteristics of individual clients that are served in a
community counseling setting.
 Understand how to conduct a bio-psychosocial assessment and know how to
interpret and conceptualize the client case.
 Be able to provide the appropriate diagnosis and treatment plan for clients, along
with completing 200 hours of activities related to diagnosis and treatment planning.
 Be able to provide appropriate referrals to community resources.
 Complete a minimum of 600 hours of which 240 hours must be in direct service,
along with one hour of supervision for every 20 hours of internship practice.
 Utilize theories and techniques to develop professional counseling relationships with
clients and client families.
 Utilize theories and techniques to develop professional counseling relationships with
agency staff and other professionals in the community.
 Be able to utilize technology to support the clinical practice, especially for
documentation purposes.
 Understand the legal and ethical issues related to the clinical internship practice.
If at all possible, there should be some experience in a variety of services. The degree of
involvement in these areas is naturally dependent upon the field site emphasis.
3
REQUIRED TEXT:
Faiver, C., Eisengart, S. & Colonna, R., (2004). The Counselor
Intern’s Handbook.
Belmont, CA: Wadsworth.
INSTRUCTIONAL METHODS AND ACTIVITIES:
This course will utilize didactic learning methods including large and small group
discussion, individual case presentations, and role-play.
ASSIGNMENTS
1. Students are required to complete a minimum of 600 clock hours of supervised
counseling experiences. A minimum of 240 of these 600 hours must be in direct
service activities with clients. Additionally, students must have a minimum of 200
clock hours of indirect and direct service experiences, which include the diagnosis,
and treatment of mental and emotional disorders and conditions.
2. Students will produce a log cataloging these experiences in appropriate clinical
counseling areas to assure some exposure to each: assessment/appraisal and
records, group work, individual counseling, consultation, resources and referral,
placement, case note procedures, evaluation, and treatment planning.
3. Students will complete an acceptable project that will be beneficial to the particular
setting. The scope to be agreed upon by the college instructor, site supervisor, and
the student.
4. Students must attend seminars as scheduled on campus for progress updates. In
addition to the seminar meetings, also required are completion of any other
assignments.
5. Case presentation.
6. Each student will be responsible for developing a portfolio that can be used for
employment seeking purposes. This portfolio may contain writing samples,
completed projects, program/grant proposals, research paper, etc.
7. Students must submit a satisfactory evaluation of performance by site supervisor.
This evaluation will verify hours completed and verify 1-hour face-to-face supervision
for every 20 client contact hours performed by the student.
Supervisor requirement:
a. The site supervisor must hold one of the following credential: LPCC, PC or
PCC and be recognized by OCSWB as a “supervising counselor”.
b. Supervision must include activities related to the Diagnosis and Treatment of
Mental and Emotional Disorders.
c. The Supervisor must include one hour of face – to – face supervisory contact
between supervisor and student for every 20 hours of internship activities.
d. The supervisor will complete an evaluation form attesting to the student’s
satisfactory completion of all the above activities in Clinical Counseling.
4
Students who have not successfully completed all internship requirements
by the final class meeting will receive an incomplete.
Students are strongly reminded of ethical considerations while enrolled in this course.
Consult the ACA Statement of Ethics or the Ohio Licensure Law for details.
**Do not hesitate to contact the instructor should you have an
ethical question.
PERFORMANCE EVALUATION CRITERIA AND PROCEDURES:
Attendance/Participation/Discussion
Completion of 600 hours/240 direct service hours/200 Diagnosis and Treatment hours
Completion of Site Project
COMPLETION OF INTERNSHIP LOG
Case presentation (In class)
Satisfactory Performance Evaluation from Internship Site Supervisor
A grade of “S” is only given if all of the above criteria are met.
ATTENDANCE POLICY:
Graduate students are training to be professional helpers responsible for the welfare of
clients in need. Attendance in professional counseling courses is required to evaluate the
readiness and preparedness of each student to enter the profession.
Attendance in counseling internship seminar is very important for progress updates. Attendance
means arriving for class on time and staying for the duration of the class. Participation means
preparing for class by reading required texts/materials and periodically entering into class discussion.
A student who misses more than 2 classes in a semester may be subject to possible action by
the instructor, which includes, but is not limited to:
 Recommendation to withdraw from the class.
 Additional assignments to complete the class.
 Reduction in grade per the percentage allotted to attendance and participation.
 Any other action deemed appropriate by the instructor.
Naturally, faculty members are sensitive to significant life circumstances that can result in
class absence. In such instances, faculty will attempt to work with these students on a case –
by – case basis.
Attendance in the counseling internship seminar is very important for progress updates.
Participation in discussions or activities is essential to satisfactory completion of the
internship.
5
SCHEDULE for COUN 671-01
Note: Additional readings will be assigned or topics may change based on the
concerns of the counseling internship class. The first half of each class will be
utilized for site updates, the second half of class will be utilized for topical
discussion or case presentations.
August 23
Overview of Class. Introductions, Review of Syllabus/Text.
Read: Chapter 1, 2 & 3
Therapeutic orientation of counselor in training.
August 30
Therapeutic orientation of internship site.
Read: Chapter 6, 7 & 8
September 6
Xavier Holiday – no class
September 13
No class. (Incompletes)
Professional Challenges
Read: Chapter 9 & 10
Log Review – Turn in copy of Log
Applying the ACA Ethical Standards
September 27
No class.
Counseling Intervention Tool – 2 presentations
October 4
Site Project Descriptions Due
October 11
No class. (Incompletes)
October 18
Counseling Intervention Tool – 2 presentations
October 25
No class
November 1
Mid – Term Evaluation Due
Counseling Intervention Tool – 1 presentations
November 8
No class
November 15
Counselors and Psychotropic Medications
Read: Chapter 4
Counselor Self Care – Compassion Fatigue – Self Test for
counselors
(Charles Figley)
November 22
No Class – (Incompletes)
Completing the Clinical Internship
November 29
Read: Chapter 11
December 6
No class.
Due: Project Summary, Log, Copy of Extension Request (if
December 13
extending internship)
(Incompletes will also meet)
Final Exam Week
**Please turn off or silence all pagers and cell phones while in class.
September 20
6
XAVIER
UNIVERSITY
Department of Counseling
3800 Victory Parkway
Cincinnati, Ohio 45207-3226
Phone (513) 745 – 3655
Fax (513) 745 – 2920
www.xavier.edu
Dear Site Supervisor,
Many thanks to you and your organization for your willingness to assist in our graduate course, COUN
671- Counseling Internship. We value the training and insights you will be giving to the Xavier graduate
student working under your direction.
The requirements for the student to successfully complete this course are as follows:
1. Students are required to complete of a minimum of 600 clock hours of supervised counseling
experiences. A minimum of 240 of these 600 hours must be in direct service activities with
clients. Additionally, students must have a minimum of 200 clock hours of indirect and direct
service experiences which include the diagnosis and treatment of mental and emotional disorders
and conditions.
2. Students will produce a log cataloging these experiences in appropriate clinical counseling areas
to assure some exposure to each one (i.e., assessment/appraisal and records, group work,
individual counseling, consultation, resources and referral, placement, case note procedures,
evaluation, and treatment planning.
3. Students will complete an acceptable project that will be beneficial to the particular setting. The
scope to be agreed upon by the college instructor, site supervisor, and the student.
4. Students must attend seminars as scheduled on campus for progress updates.
5. Students must submit a satisfactory evaluation of performance by site supervisor. This evaluation
will verify hours completed and verify 1 hour of face-to-face supervision for every 20 client
contact hours performed by the student.
A grade of “S” is only given if all of the above criteria are met.
The instructor will be contacting you during the semester to discuss the progress of our student. Please do
not hesitate to contact us at any time should you have comments, questions, or concerns.
Again, thank you for your contribution to Xavier and the helping professions.
Sincerely,
Dr. Butch Losey
Clinical Coordinator
loseyr@xavier.edu
7
Obtaining Internship Approval
The State of Ohio Professional Counselor Training Supervision Agreement on the following pages
must be filed with the Ohio Counselor, Social Worker and Marriage & Family Therapist Board to
request approval to begin the internship if you are seeking counselor in training status.
You will note that the student completes the first two pages of the form and the supervisor must
complete the last page.
Proof of enrollment in the internship (e.g. a copy of your class registration or a copy of your
unofficial transcript) showing your registration will suffice) must accompany this form.
Likewise, your supervisor must attaché a “Professional Disclosure Statement” with the form.
Students should submit the original of this form to The Ohio Counselor, Social Worker and
Marriage & Family Therapist Board and a copy of it to the Xavier Clinical Coordinator.
When the State of Ohio approves the internship, an approval letter will be sent to the student (see
sample p. 10). Again, a copy of this approval should be given to the Xavier Clinical Coordinator
to include in your file.
8
9
10
11
ATTACH THE SITE SUPERVISOR
PROFESSIONAL DISCLOSURE STATEMENT
TO THIS TRAINING SUPERVISION
AGREEMENT
12
State of Ohio
Counselor, Social Worker, and Marriage & Family Therapist Board
50 West Broad Street, Suite 1075, Columbus, OH 43215-5919
(614) 466-0912
To:
Student
Street
Cincinnati, OH
From:
January 15, 2006
Rena Elliott, Administrative Assistant
Please examine the checklist below for review of the experience and/or other documentation submitted to the Board. If
you have questions concerning the items marked with an “X” please contact Pat Sposito, Administrative Assistant at
the Board office.
X
1.
Your supervised experience is approved for the dates and supervisor’(s) listed below only. You must follow all
supervision rules to receive final approval for your experience. If this item is marked with an “X” you may now refer
to yourself as a “COUNSELOR TRAINEE.” See OAC 4757-3-01(t) and OAC 4757-13-04 for clarification.
DATES: 1/03-6/03
SUPERVISOR: John Doe
2.
Because your experience was not filed prior to the beginning of the training, per OAC section 4757-13-04 (B)(2) the
Board will only accept the experience from 60 days prior to receipt at the Board office.
3.
Please send an unofficial or Xerox copy of your transcript so the Board may determine evidence of meeting the
educational requirements or proof of enrollment in an approved Practicum/Internship. If you meet the educational
requirements of section 4757-13-01 of the OAC, you will be sent the information regarding your eligibility for
admission to the examination.
4.
“Counselor Trainee” status is for students enrolled in an approved Practicum or Internship (see OAC 4757-3-01(T) or
for individuals who passed the LPC exam prior to December 31, 1998 and are completing 4,500 hours of supervision
(see OAC 4757-13-04).
5.
You have not completed ninety quarter or sixty semester hours of graduate credit in counseling training as defined in
section 4757-13-01 of the OAC to qualify for PC/PCC licensure. Thirty quarter or twenty semester hours must cover
5 clinical course content areas outlined in section 4757-13-01 of the OAC.
6.
It does not appear that your supervisor has the proper credentials to supervise. Therefore, you should seek a
supervisor who meets the requirements for supervision.
7.
Approved Supervisors after June 30, 2000 must be an (L)PC or an (L)PCC with the “Supervising Counselor”
credential. Cases of hardship may be reviewed.
8.
The work duties described do not appear to be professional counseling or clinical counseling as described in section
4757.01(A) and (B) of the ORC.
9.
Please complete the attached coursework worksheet and return to determine if there may be any deficiencies.
10.
Please send a copy of your college catalog so that the board can review your degree.
***ADDITIONAL COMMENTS OR INSTRUCTIONS:
13
EXPECTATIONS FOR XAVIER INTERNS
COUN 671
This form should be signed and returned to the Clinical Coordinator to include in your internship file
before beginning the experience.
1. I will at all times conduct myself in an ethical fashion in my activities with clientele and
in carrying out my duties related to my internship site. The American Counseling
Association’s Code of Ethics shall serve as a guide to my professional behavior with
client and agency confidentiality given the utmost respect..
2. My dress will reflect professional attire appropriate to my internship site.
3. I will meet regularly with my internship site supervisor and will follow the directions of
that individual to the best of my ability.
4. I will accurately and honestly complete logs, regularly attend on-campus class meetings,
and fulfill other assignments required as part of my internship experience.
5. I have read and am familiar with the Xavier University Affiliation Agreement (pg. 16)
6. I will not hesitate to consult with my supervisor if I am concerned about my ability to
provide services to a client or if I am assigned responsibilities that seem beyond my level
of professional expertise.
7. Should a conflict, potential conflict, or other concerns arise regarding my internship
activities, I will consult with my internship site supervisor. Should this consultation fail to
address my concerns adequately, I will immediately notify my Xavier supervisor.
8. Should I choose to cease my internship activities at a particular site, I will give
appropriate notice to my supervisor and make provisions for the continued appropriate
care of my clientele. In short, I will not abandon my clients. I realize that appropriate
notice will vary dependent upon my internship activities and responsibilities.
Student Signature
14
Date
15
XAVIER AFFILIATION AGREEMENT AND INSTRUCTIONS
On the following pages is an Affiliation Agreement that defines the relationship between Xavier
University and your internship site.
You will note that this is a “Fill-in-the-Blank´ form that requires your supervisor’s signature on the
second page.
Please familiarize yourself with the terms of the Agreement and note that you are covered with
liability insurance through the University as described in Item 9.
Students are also encouraged to purchase their own liability insurance policies. An affordable policy
is available to student members of the American Counseling Association. Call 1-800-347-6647 x 284
or visit www.counseling.org for more information.
The signed Affiliation Agreement must be returned to the Xavier Clinical Coordinator before students
may begin the internship experience.
TB Testing
Some organizations will require practicum/intern students to show evidence of a recent
negative TB test.
Students can contact their physician or the Xavier Health and Counseling Center to schedule
an appointment for the test.
The Health and Counseling Center charges $15 and schedules the tests on Mondays,
Tuesdays, Wednesdays, and Fridays between the hours of 8:30 AM – 4:30 PM.
Call (513) 745- 3022 for details.
Finger-Printing/Background Checks
Likewise, some practicum/internship sites will require a background check and finger
printing.
Refer to the Attorney General’s website at http:/www.ag.state.oh.us/
or contact the BCI&I in London, Ohio at (740) 845-2375 will all fingerprinting questions.
Students are strongly encouraged to investigate specifically if the TB Test and /or the
background checks are required with the practicum/intern site before scheduling these
steps.
16
Xavier University
COUN 671
GRADUATE COUNSELING INTERNSHIP AFFILIATION AGREEMENT
BETWEEN
AND
XAVIER UNIVERSITY, Cincinnati, OH
This agreement is entered into this
day of
, 20
, by and
between Xavier University (hereinafter “University” and
,
(hereinafter “Facility”) for the purpose of providing Counseling Internship Experiences for
, a Graduate Counseling student at the University.
Both parties recognize the need for clinical counseling experiences at sites providing
assistance to clients needing a wide range of services. The purpose of these clinical
experiences is to provide Graduate Counseling students opportunities for extended
observation and participation, with the understanding that these experiences will be integrated
with course work within the Graduate Counseling Program curriculum. In order to
accomplish this purpose, the following practices will be observed:
1. The University will be responsible for establishing objectives for the experiences,
and for providing these to the Facility.
2. The University will schedule the student for these experiences in collaboration with
the Facility and consistent with accepted non-discriminatory practices.
3. The Facility will provide supervision of the student on site by qualified, competent,
and appropriately credentialed personnel; these persons will be designated as “onsite supervisors.”
4. The University will provide the student with information regarding expectations for
the experiences and with general instruction in information needed to participate in
these experiences.
5. On-site supervisors will provide the student additional instruction as needed for the
student to perform specific assigned tasks.
6. The University will provide the on-site supervisor with forms to be used in
evaluating student performance. Supervisors will complete the forms and return
them to the University, to be used in assigning the student grades for the
experiences.
17
7. The Facility will hold itself available at all reasonable times, as designated by the
University in consultation with the Facility, for the Internship experiences of the
Graduate Counseling student of the University.
8. The University (including both faculty and student) agrees to respect the
confidentiality of the clients of the Facility.
9. The University shall provide evidence of professional liability insurance coverage
in the amount of $2,000,000/$4,000,000 for all its students, employees and agents
who are assigned supervisory or administrative duties in the Facility in connection
with the affiliation of the University’s students.
This agreement will be deemed in effect indefinitely unless one or both parties submit 30
days written notice for cancellation. In the event of cancellation, both parties will observe all
obligations under the agreement until the end of the University’s academic semester during
which cancellation occurs.
The signatures below attest to agreement to abide by the described practices:
________________________________________________
Site Supervisor
Date
Site Supervisor Information:
Phone number__________________
Print Name_______________________________________
Email_________________________
Supervisor Credentials______________________________
Dr. Butch Losey, Ed.D., PCC-S, NCC
Clinical Coordinator
Department of Counseling
Xavier University
Date
Dr. Scott A. Chadwick
Date
Provost and Chief Academic Officer
Xavier University
18
TYPE KEY:
Direct Service = DS
Diagnosis & Treatment = DX
Supervision = S
Class Meetings = CM
Documentation = DOC
Other = O
COUN 671 - COUNSELING INTERNSHIP LOG
Name:
SS #:
Date:
Placement Site:
Site Supervisor:
Do not include confidential information (e.g. client names) on this log!
DATE
ACTIVITY
TYPE
TIME (in clock hours)


Please total hours for each type of service for each page:
DS:
DX:
DOC:
Total of all types:
19
CM:
O:
S:
DATE
ACTIVITY
TYPE
TIME (in clock hours)


Please total hours for each type of service for each page:
DS:
DX:
DOC:
Total of all types:
20
CM:
O:
S:
DATE
ACTIVITY
TYPE
TIME (in clock hours)


Please total hours for each type of service for each page:
DS:
DX:
DOC:
Total of all types:
21
CM:
O:
S:
DATE
ACTIVITY
TYPE
TIME (in clock hours)


Please total hours for each type of service for each page:
DS:
DX:
DOC:
Total of all types:
22
CM:
O:
S:
DATE
ACTIVITY
TYPE
TIME (in clock hours)



Please total hours for each type of service for each page:
DS:
DX:
DOC:
Total of all types:
23
CM:
O:
S:
DATE
ACTIVITY
TYPE
TIME (in clock hours)


Please total hours for each type of service for each page:
DS:
DX:
DOC:
Total of all types:
24
CM:
O:
S:
DATE
ACTIVITY
TYPE
TIME (in clock hours)


Please total hours for each type of service for each page:
DS:
DX:
DOC:
Total of all types:
25
CM:
O:
S:
DATE
ACTIVITY
TYPE
TIME (in clock hours)


Please total hours for each type of service for each page:
DS:
DX:
DOC:
Total of all types:
26
CM:
O:
S:
DATE
ACTIVITY
TYPE
TIME (in clock hours)


TOTAL - DS:
DX:
S:
CM:
O:
DOC:
=
We certify that the above information is accurate and complete.
Signature of Student
Date
Signature of Site Supervisor
Date

27
grand total hrs.
Field Project Information
The Counseling Internship requires the completion of a project that will be useful to the placement
site.
Ideas for the project should be discussed with the supervisor and then submitted to the Xavier
Clinical Coordinator for approval. The form on the following page is to be used to submit the
proposal.
Xavier approval of the project is necessary to insure that the activities are appropriate for the intern
and contribute to learning. Also, projects that are excessive in their scope and/or time demands can be
avoided.
When the project is complete, students are asked to submit a 1-2 page summary of the project. This
summary should include a brief rationale for the project, a summary of the project activities, and
results of the effort.
Hours spent on the project can be logged toward the 600-clock hour requirement.
Possible Site Projects:

Update community referral resource manual.

Develop the curriculum for a psychoeducational group.

Develop, implement, and evaluate a group.

Conduct a literature review for a specific clinical disorder.

Research an evidence based intervention and provide a training seminar to agency staff.

Research and write a grant for the agency to secure funding for a specific project.
28
Field Site Project Description
COUN 671
Name
Address
Phone
Field Placement:
Institution Name
Address
Phone
Brief description of project:
Rationale for the project:
Supervisor Authorization of Project
(Signature)
Date
29
Requesting an Extension from the Ohio Counselor, Social Worker and
Marriage & Family Therapist Board
Internship requires a completion of 600 clock hours which students sometimes may not
complete in one semester. Therefore, an extension needs to be requested from the Ohio
Counselor, Social Worker and Marriage & Family Therapist Board and Xavier University.
To begin the process, please first contact Dr. Losey and request the extension. If the
extension is granted by Dr. Losey, please complete the required forms and submit to the
Ohio Counselor, Social Worker and Marriage & Family Therapist Board. If the extension is
longer than 30 days, the will need to register for an addition credit hour of internship and
attend class sessions.
The Ohio Counselor, Social Worker and Marriage & Family Therapist Board typically will
approve an internship experience for one semester. If you expect multiple extensions please
photo copy the form as needed.
30
XAVIER
UNIVERSITY
Department of Counseling
3800 Victory Parkway
Cincinnati, Ohio 45207-3226
Phone (513) 745 – 3655
Fax
(513) 745 - 2920
To:
From:
State of Ohio
Counselor, Social Worker, and
Marriage & Family Therapist Board
50 West Broad Street, Suite 1075
Columbus, OH 43215-591
Dr. Butch Losey
Clinical Coordinator
Date:
___________________
As you know, the Master’s Program in Community Counseling at Xavier focuses upon a
part-time student population. Therefore, our students will typically need several semesters
to complete the 600 clock hour clinical counseling internship requirement.
For example, a student may enroll for the internship in one semester, but receive an
incomplete grade in that internship until all requirements are met. However, in this
circumstance, the student should be considered actively enrolled in the internship
experience.
This memo certifies that ___________________________________________
(SS# _______________ - ___________ - _______________________) has
received an incomplete grade in COUN 671, Counseling Internship (indicated by an “M” on
the transcript) but remains actively involved in completing the requirements .
This student remains under the supervision of
__________________________________,
Ohio Counselor license #
__________________________________________________.
It is anticipated that the internship requirements will be completed on or before
______________________ , ___________________________________.
Thank you for your understanding and assistance in this matter.
31
32
33
XAVIER
UNIVERSITY
Department of Counseling
3800 Victory Parkway
Cincinnati, Ohio 45207-3226
Phone (513) 745 – 3655
Fax
(513) 745 – 2920
Date:
To:
__________________________________
From: __________________________________
Subject:Internship
If you will be receiving an incomplete in the Internship Class, please complete the bottom
half of this form. We need to know as soon as possible your status with your completed
hours or your intent to complete your hours. Indefinite incompletes can no longer be
accommodated without authorization.
Please complete this form and fax or mail it immediately to:
Dr. Butch Losey
Clinical Coordinator
3800 Victory Parkway
Cincinnati, Ohio 45207-3226
Office: (513) 745-1037
Fax: (513) 745-2920
Name _____________________________________________________
Email Address ______________________________________________
Daytime Phone # ____________________________________________
Cell Phone # ________________________________________________
Internship Placement _________________________________________
Total hours completed to date ___________________________________
Expected date of internship completion ____________________________
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Student Evaluation Procedures
Grading for the Internship Course is on a “Satisfactory/Unsatisfactory” basis.
To earn a “S” grade, students must:
 Attend and participate at on-campus class sessions.
 File all forms and other required paperwork by course deadlines.
 Consistently adhere to ethical considerations and demonstrate professional responsibility to the
internship site.
 Consistently demonstrate an openness to supervisor critique and a willingness to learn.
Student progress in the internship experience is monitored in several ways. These may include:
 Clinical Coordinator visits to discuss student progress with the site supervisor.
 Telephone consultations with site supervisors.
 Site Supervisor completion of the Interim Evaluation From (see next page).
 Site Supervisor completion of the State of Ohio Internship Supervisor Evaluation Rating Form
(see pp. 29 - 32).
The original of this form must be filed with the Ohio Counselor and Social Worker Board and a copy
with the Xavier Clinical Coordinator within thirty days of the successful completion of the internship
to serve as the final student evaluation.
Please note that all supervisors must complete this form during the internship. That is, if a student
changes internship sites or supervision during the experience, an Evaluation Form must be completed
by each supervisor.
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Interim Evaluation Form
Supervisor Name:
Intern Name:
(please print)
(please print)
Supervisor Signature:
Address:
Phone:
Date:
At present the intern under my supervision:
EXCEEDS
1.
2.
3.
4.
5.
MEETS
Has an awareness of his/her own strengths and
limitations
Uses supervision for personal and professional
growth.
Hears and understands the supervisor’s feedback
during supervision.
Openly and appropriately communicates with
the supervisor.
Readily seeks supervisory direction when
needed.
6.
Initiates appropriate working relationships with
clients
7.
Follows ethical procedures (e.g. confidentiality)
in client relationships and in regard to
organizational issues.
8.
Is able to define appropriate counseling goals
with clients.
9.
Is accepting of client differences.
Can articulate and provide a rational for
10. treatment approaches.
11. Keeps all required records up to date.
OVERALL:
Is successfully fulfilling internship
12. responsibilities.
13. I have a concern, please contact me to discuss.
Return to: Dr. Butch Losey
3800 Victory Parkway
Cincinnati, Ohio 45207-3226
(513) 745-3037
(513) 745-2920 – fax
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Return by:
BELOW
N/A
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XAVIER
UNIVERSITY
Department of Counseling
3800 Victory Parkway
Cincinnati, Ohio 45207-3226
Phone (513) 745 – 3655
Fax (513) 745 – 2920
Confidential Internship
Site Evaluation Form
Intern’sName_____________________________________________________
Date of Evaluation _______ Name of Agency ______________________________
Agency Supervisor _____________________ Title & license __________________
Internship dates ________________ to _________________ Total # hours ______
Complete this form when you complete your internship. If you have multiple sites please
submit an evaluation form for each location.
THE SITE
4 = Outstanding
1.
2.
3.
4.
5.
6.
7.
8.
3 = Good
2 = Fair 1 = Poor
NA = Not Applicable
Overall agency operations and administration
Introduction to agency mission and structure
Awareness of roles of administrative staff
Knowledge of agency goals
Understanding of agency care standards
Policies on risk management (including duty to warn)
Policies on confidentiality of records
Policies regarding maintenance of records
__________
__________
__________
__________
__________
__________
__________
__________
Comments:
THE SUPERVISOR
4 = Outstanding
3 = Good
2 = Fair 1 = Poor
NA = Not Applicable
Please rate your supervisor’s ability to assess/develop you in these areas.
1. Communication skills
2. Assessment
3. Diagnosis (including knowledge of DSM-IV)
4. Treatment (including treatment planning and termination)
5. Case management
6. Agency operations and administration
7. Professional orientation
8. Knowledge and application of professional ethics
9. Ability to process my professional issues with supervisor
10. Group Work
11. Counseling
12. Consultation
13. Referral
Comments:
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__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
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