Supervised Training Hours

		Doctoral		Terminal Masters
a. Individual Therapy		Total hours face-to-face	# of different individuals	Total hours face-to-face	# of different individuals

	1) Older Adults (65+)	0	0	0	0
	2) Adults (18-64)	85.50	28	0	0
	3) Adolescents (13-17)	0	0	0	0
	4) School-Age (6-12)	0	0	0	0
	5) Pre-School Age (3-5)	0	0	0	0
	6) Infants / Toddlers (0-2)	0	0	0	0

b. Career Counseling

	1) Adults	0	0	0	0
	2) Adolescents	0	0	0	0

c. Group Therapy		Total hours face-to-face	# of different groups	Total hours face-to-face	# of different groups

	1) Adults	260	72	0	0
	2) Adolescents (13-17)	0	0	0	0
	3) Children (12 and under)	0	0	0	0

		Doctoral		Terminal Masters
d. Family Therapy		Total hours face-to-face	# of different families	Total hours face-to-face	# of different families

		0	0	0	0

e. Couples Therapy		Total hours face-to-face	# of different couples	Total hours face-to-face	# of different couples

		0	0	0	0

f. School Counseling Interventions		Total hours face-to-face	# of different individuals	Total hours face-to-face	# of different individuals

	1) Consultation	0	0	0	0
	2) Direct Intervention	0	0	0	0

g. Other Psychological Interventions		Total hours face-to-face	# of different individuals	Total hours face-to-face	# of different individuals

	1) Sports Psychology / Performance Enhancement	0	0	0	0
	2) Medical / Health – Related Interventions	0	0	0	0
	3) Intake Interview / Structured Interview	212.00	212	0	0
	4) Substance Abuse Interventions	22.50	97	0	0
	5) Other interventions	0	0	0	0

		Doctoral		Terminal Masters

h. Psychological Assessment Experience		Total hours face-to-face	Total hours face-to-face

	1) Psychodiagnostic Test Administration	64.00	0
	2) Neuropsychological Assessment	0	0

i. Other Psych. Exp. W/ Students and/or Orgs.		Total hours face-to-face	Total hours face-to-face

	1) Supervision of other Students	0	0
	2) Program Development/Outreach Programming	236.00	0
	3) Outcome Assessment of Programs or Projects	0	0
	4) Systems Intervention/ Org consult./ Perf. Improvement	0	0
	5) Other (Specify)	0	0

	Total Intervention & Assessment Hours:	880.00	0

		Doctoral	Terminal Masters
Supervision Received		Total hours	Total hours

	a. Hours spent in one-to-one face-to-face supervision	127.25	0
	b. Hours spent in group supervision	99.00	0
	c. Hrs of peer spvsn/consult. and case discussion on spec. cases	133.00	0
	Total Supervision Hours:	359.25	0

Summary of Practicum Hours		Doctoral	Terminal Masters	Total Hours

	a. Total intervention and Assessment hours:	880.00	0	880
	b. Total Supervision hours:	359.25	0	359.25
	Grand Total:	1239.25	0	1239.25

		Doctoral	Terminal Masters
Support Activities		Total hours	Total hours

	a. Case Conferences	79.50	0
	b. Case Management/Consultation	1.00	0
	c. Didactic Training/Seminars/Grand Rounds	162.50	0
	d. Progress Note/Clinical Writing/Chart Review	256.50	0
	e. Psych. Assess. Scoring/Interp. and Report Writing	128.00	0
	f. Video-Audio-Digital Recording Review	42.00	0
	Total Support Hours:	669.5	0


Treatment Settings		Doctoral	Terminal Masters	Total	Clinical Work Experience

	Child Guidance Clinic	0	0	0	0
	Community Mental Health Center	0	0	0	0
	Department Clinic (psychology clinic ran by dept or school)	0	0	0	0
	Forensic/ Justice Setting (e.g. jail, prison)	0	0	0	0
	Inpatient Psychiatric Hospital	0	0	0	0
	Medical Clinic/Hospital	419.00	0	419	0
	Outpatient Psychiatric Clinic/Hospital	608.25	0	608.25	0
	University Counseling Center/ Student Mental Health Center	0	0	0	0
	Schools	0	0	0	0
	VA Medical Center	0	0	0	0
	Other (specify)	212.00	0	212	0
	Total hours in All Treatment Settings	1239.25	0	1239.25	0

		Number of Different Clients / Patients Seen
Race / Ethnicity		Intervention	Assessment

	African-American/ Black/ African Origin	25	16
	Asian American /Asian origin/ Pacific Islander	1	0
	Latino-a/ Hispanic	9	24
	American indian/ Alaska Native/ Aboriginal Canadian	0	3
	European Origin/ White	70	165
	Bi-racial/ Multi-racial	6	4
	Other	1	0

Sexual Orientation

	Heterosexual	6	186
	Gay	80	18
	Lesbian	17	5
	Bisexual	3	2
	Other	4	1

Disabilities

	Physical/ Orthopedic Disability	9	83
	Blind/ Visually Impaired	0	0
	Deaf/ Hard of Hearing	0	0
	Learning/ Cognitive Disability	1	0
	Developmental Disability	0	0
	Serious Mental Illness	47	14
	Other	0	0

Gender

	Male	87	95
	Female	22	116
	Transgendered	3	1

David Godot