Internship Supervisee Weekly Log Of Activities
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2Internship Supervisee Weekly Log of Activities
Month/Year________
Supervisee’s Name
Work setting in which Supervision took place
Supervised hours for the week ending
Supervision & Training
Face-to-face individual supervision with primary supervisor
Face-to-face individual supervision with delegated supervisor
Group supervision with primary or delegated supervisor
Training Activities
Professional Services Performed
Individual psychotherapy
Couples, children & /or family psychotherapy
Group psychotherapy
Testing & assessment (face-to-face administration, feedback session)
Intakes
Consultations
Other Work Performed
Case management (case notes, test interpetation and report writing, etc.)
Staff meetings
Administrative duties
Other professional activities (describe)
Total number of hours of supervised experience per week
Total number of hours of SPE performed satisfactorily
Primary supervisor’s printed name and psychology license number
Primary supervisor’s signature and date
I certify that the information on this form accurately represents the training
activities
Delegated supervisor’s printed name, license type and number
Of ___________________________________________
(Supervisee)
Delegated supervisor’s signature
At_______________________________________________
(Work setting)
Delegated supervisor’s printed name, license type and number
Primary supervisor’s printed name and psychology license number
_________________________________________
Delegated supervisor’s signature
Primary supervisor’s signature and date
________________________________________
Supervisee’s signature and date
Published as a courtesy to psychology interns by the California Psychology Internship Council (CAPIC), 100 Ellinwood Way, Pleasant Hill, CA 94523
New (2016-17) suggested categories are highlighted in yellow. See the Section 1387.5 of the California Code of Regulations for exact regulations.
Form available for download at
Phone: 925-969-4550. Email: capicadmin@capic.net
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