MAMFT Clinical Hours Summary

Date

Student

First NameLast Name

Student E-mail

example@example.com

State Seeking Licensure In

Select your current clinical course name

Select your Specialization

Select Current University Group Faculty

Liability Expiration Date

Date

Indicate your site(s), supervisor(s), and status for each. Please note that you need to communicate ANY changes in your site to the clinical admin team at MFTtraining@nu.edu:

Rows	Name of Site	Supervisor for Site	Status of Site
Site One
Site Two
Site Three
Site Four
Site Five

Based on the licensing state you selected, you will need more hours than the minimum program requirements. See the information below related to specific state requirements.

500 direct client contact hours: Alabama, Arkansas, Kansas, Mississippi, Rhode Island, and Wyoming
450 direct client contact hours: Virginia
250 relational hours: Alabama, North Dakota, and Rhode Island
200 relational hours: Arkansas, Mississippi, Virginia, and Wyoming
100 hours of Local Supervision: California

If you need additional information about licensure requirements, please contact the licensure division of your state.

MAMFT THERAPY Hours APPROVED in Clinical Tracking System

Rows	Student: List APPROVED Hours ONLY
TOTAL DIRECT THERAPY (Individual + Relational) - 300 minimum required
RELATIONAL - 150 minimum required
IN-PERSON - 50 minimum required
CO-THERAPY - 50 maximum allowed
SPECIALIZATION - 50 minimum required (if applicable)

Please acknowledge the following the statements:

MAMFT SUPERVISION Hours APPROVED in Clinical Tracking System

Rows	Student: List APPROVED Hours ONLY
TOTAL UNIVERSITY SUPERVISION - 100 minimum required
University Observable Data - 50 minimum required
TOTAL LOCAL SUPERVISION
LOCAL INDIVIDUAL SUPERVISION - 52 minimum required
IN-PERSON SUPERVISION- 12 minimum required

The reports to be uploaded below reflect the approved hours that will be reported on any state forms.

Please upload the #523 Report - Approved Hours Log from ELC.

Please upload the #514 Report (for co-therapy and specialization hour tracking) from ELC.

If students do not have the minimum hours needed or they are not clinically ready, an extension course will be scheduled prior to the 4-week long Capstone course. The extension courses are either 4, 8, or 12 weeks in length.

The length of the extension course needed is determined based on any required revisions to your Capstone draft and the direct client contact hours you have left to accrue.

Please review the guide below to review hours requirements. Note that this chart is based on students obtaining 300 total direct client contact. If your state exceeds this, your faculty can support you in selecting the appropriate course. You can also review your state specific information at this link.

Faculty, please sure to also comment in the section below on the student's clinical readiness based on the Capstone draft.

The ranges are intended to serve as a guide for students, and faculty in determining if extension courses are needed. If the student requests a shorter extension than what is indicated or to skip an extension altogether, students will be asked to provide a plan to be approved by faculty. Students will also assume the risk of failing Capstone and having to retake the course if hours are not met.

FOR STUDENTS IN INTERNSHIP II OR AN EXTENSION COURSE: Based on the above explanation, which course are you eligible for based on your APPROVED hours in Tevera

During the past 10 weeks that you have been enrolled in this course, have you worked with at least one client who fits the COAMFTE Definition of Diverse, Marginalized, and/or Underserved Communities?

Did you earn client or supervision hours prior to your NU clinical experience that NU accepted?

Please share any information you'd like the clinical team to know about your current hours accrual:

I acknowledge that I, First Name* Last Name* , understand that if I proceed into the capstone course, but do not meet the hours requirements for graduation before capstone ends, I will fail the capstone course. I understand that I am required to have observable data to present for my capstone presentation, which serves as the final deliverable for the MAMFT degree. I also acknowledge that the absence of observable data will result in unsuccessful completion of the degree requirements. I understand that I must remain clinically active throughout the duration of my course to obtain participation credit.

Acknowledgement and understanding of the statement above about program requirements.

Your faculty will complete their section of this form. Upon completion you will receive an email.

For Faculty Use Only

Has this student completed all required evaluations within this course?

If NO, please still submit this form and encourage your student to complete and submit the evaluations as soon as possible. These evaluations are needed in order to close out the course.

Are reported clinical hours accurate?*

*Please review the student's state of intended liensure and specialization for accuracy. https://form.jotform.com/SBSNU/state-and-spec-course-information

MAMFT THERAPY Hours APPROVED in Clinical Tracking System

Rows	Student: List APPROVED Hours ONLY	Faculty: Any Adjusted Hours
TOTAL DIRECT THERAPY (Individual + Relational) - 300 minimum required
RELATIONAL - 150 minimum required
IN-PERSON - 50 minimum required
CO-THERAPY - 50 maximum allowed
SPECIALIZATION - 50 minimum required (if applicable)

MAMFT SUPERVISION Hours APPROVED in Clinical Tracking System

Rows	Student: List APPROVED Hours ONLY	Faculty: Any Adjusted Hours
TOTAL UNIVERSITY SUPERVISION - 100 minimum required
*University Observable Data - 50 minimum required
TOTAL LOCAL SUPERVISION - 100 required for CA students only
LOCAL INDIVIDUAL SUPERVISION - 52 minimum required
IN-PERSON SUPERVISION- 12 minimum required
*Local Observable Data - no minimum

The student has specified they have the {selectYour143} specilization. Please review the specilization hours.

Based on the students hours and Capstone draft, which course should the student enter next?

I understand that if the student does not complete the remaining hours in all categories during the capstone course, they will fail the course and have to retake it.

Do students have the APPROVED hours to enter into Capstone?

Please indicate why you support Capstone entry without approved hours required above.

Did the student pass the Capstone draft?

Please provide additional information and/or recommendations pertaining to the student's clinical readiness. Specifically, we would like you to comment on clinical skills and progress as seen from case presentations:

Faculty Signature

Date

For Administrator Use Only

Admin Review of Final Hours

Clinical Team Comments