Licensure & supervision worksheet
Clinical Supervision Log
A paper record of supervised clinical experience toward licensure — session by session, with hours, focus, and supervisor sign-off. Print a fresh sheet for each period and keep signed copies for your board file.
Name or initialsDate
How to use this worksheet
Log each supervision session as it happens and have your supervisor initial each row— contemporaneous, signed records are what boards expect. Record hours to your board's definitions (individual vs. group, direct clinical vs. indirect), since requirements differ by license. Confirm current supervised-experience rules with the NH Office of Professional Licensure and Certification before you rely on any total here.
Supervisee & supervisor
Supervisee
License sought
Supervisor
Supervisor license & #
Agency / setting
Reporting period
Supervision sessions
One row per session. Mark whether the hours were direct clinical supervision, and have the supervisor initial each entry.
Date
Hrs
Format (Ind / Grp)
Direct ✓
Topics, cases & focus of supervision
Supervisor initials
Running totals
Carry these forward across sheets to track progress toward your board's requirement.
Hours this sheet
Cumulative hours to date
of which individual supervision
of which group supervision
Direct client-contact hours
Hours remaining to requirement
Supervisor attestation
By signing, the supervisor confirms the sessions above took place as recorded.
Supervisor signatureDate
Supervisee signatureDate