Graduate-Level Practicum, Internship, or Field Experience

DH‐MQA5047,8/2020,Rule64B4‐3.0085 Page1of1

Submit form to the board office at:

BoardofClinicalSocialWork,MarriageandFamilyTherapy,

andMentalHealthCounseling

4052BaldCypressWayBinC‐08

Tallahassee,FL32399‐3258

Graduate‐LevelPracticum,Internship,

orFieldExperienceVerificationForm

MENTALHEALTHCOUNSELING

Use this form to document practicum hours earned outside the academic setting

to meet the 700 practicum-hour requirement. The form must be completed by the supervisor.

Applicant Name: ________________________________________________________________

Florida Intern Registration Number (if applicable): IMH__________________________

1. SUPERVISOR INFORMATION

Supervisor Name: ___________________________________________ Telephone: _________________________

Addre

ss: _____________________________________________________________________________________

Street City State ZIP

Email Address: ________________________________________________________________________________

Under Florida law, email addresses are public records. If you do not want your email address released in response to a public

records request, do not provide an email address or send electronic mail to our office.

License Title State

Original

Licensure Date

(

MM/DD/YYYY

)

License Number

2. SUPERVISED PRACTICUM HOURS

A. Dates of supervision: Start Date: ___________________ End Date: _____________________

MM/DD/YYYY Provide specific date - MM/DD/YYYY

B. The applicant/intern worked an average of ___________ hours per week, for a total of ___________ clock hours.

3. SUPERVISOR STATEMENT

I have read and understand section (s.) 491.005(4)(b)1.c., Florida

Statutes (F.S.), which states in part, the

requirement of at least 700 hours of supervised clinical practicum, internship, or field experience as required in the

accrediting standards of the Council for Accreditation of Counseling and Related Educational Programs (CACREP). I

provided weekly interaction that averaged one hour per week of individual and/or triadic supervision. I evaluated the

intern’s performance throughout and at the conclusion of my supervision. Additionally, for every 100 clock hours, at

least 40 of those hours were of direct service, totaling 280 hours.

Has the applicant met the minimum standards of performance in professional activities as measured against generally

prevailing peer performance, pursuant to s. 491.009(1)(r), F.S.? Yes No

If “No,” you must provide further information to explain why this requirement has not been met.

Supervisor Signature: ___________________________________________________ Date: ____________________

MM/DD/YYYY