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Weekly Counseling Activity Record Form
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San Jose State University - Counselor Education Program
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Enter Your Name Here
Enter Field Site (and District if applicable) Here
Semester and Year
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Type of Placement?
In addition, these hours fulfill requirements for:
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____Elem____Middle____
CWA - Outside Agencies:
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High Schl
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Higher Ed
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Professional Clinical Counseling Pathway
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NonProfit/Comm Agency
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Number of direct hours that met these categories?
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Week of:# of Hrs: Site Super- vision Check In# of Hrs: Indirect Coun- seling# of Hrs: Direct Coun- selingTOTAL Hours#Activities - Include details about the activities completed during the week, including both direct and indirect counseling services provided. What unique functions were fulfilled during the week?Group Counsel*Students with Diverse IdentitiesAcad CounselSoci/ Emotional CounselCollege/ Career Counsel# of Hrs - Professional Clinical Counseling face-to-face requirement# of Hrs - CWA interdisci- plinary requirement
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TOTAL HRS:
00000000000
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(Date)
(Field Site Supervisor Signature - Docusign, Adobe Sign or wet signature)
(Site Supervisor Name and credentials)
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* As defined by the CTC: Students with diverse identities include socioeconomic disadvantages, English learners, homeless youth, foster youth, students with disabilities (including 504 plans), students experiencing suspension from school, sexual and gender minority youth (LGBTQ+), racial and ethnic minorities.
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