Form 4b - Certification Of Experience For Licensed Clinical Social Worker Page 4

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Psychotherapy Log: Use this weekly log to document the applicant’s hours of practice and supervision for Licensed
Page
Clinical Social Worker. All pages of the log must be retained by the supervisor, in the event the
-State Board requests clarification. Please photocopy this log as needed.
_____ of _____
Applicant name: __________________________________ Supervisor name: __________________________________
Week starting date for
Supervision Type
Client Contact
Supervision
psychotherapy
Applicant Initials
(Individual, Group, Peer,
Supervisor Initials
Hours/Week*
Hours/Week**
(mm/dd/yy)
Case)**
_______ / _______ / _______
_______ / _______ / _______
_______ / _______ / _______
_______ / _______ / _______
_______ / _______ / _______
_______ / _______ / _______
_______ / _______ / _______
_______ / _______ / _______
_______ / _______ / _______
_______ / _______ / _______
_______ / _______ / _______
_______ / _______ / _______
_______ / _______ / _______
_______ / _______ / _______
_______ / _______ / _______
_______ / _______ / _______
_______ / _______ / _______
_______ / _______ / _______
_______ / _______ / _______
_______ / _______ / _______
*Contact hour = 45 Minutes of psychotherapy (shorter sessions may be combined)
**Supervision = at least 100 hours of in person supervision over the period of at least 36 months and not more than 72 months.
Licensed Clinical Social Worker Psychotherapy Log, Rev. 11/15

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