MAMFT Clinical Hours Summary

Date*

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:

	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 therapy 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

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

{student}, for these hour tables ONLY enter in numbers in the first open column that is titled "Student: List APPROVED Hours ONLY." Do NOT add any hours to the Faculty or Admin columns.

MAMFT THERAPY Hours APPROVED in Clinical Tracking System

	Student: List APPROVED Hours ONLY	Faculty: Any Adjusted Hours	Admin: 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)

Do you have less than 142 total approved direct therapy hours OR less than 72 approved relational therapy hours?

YESNO

Do you have less than 200 total approved direct therapy hours OR less than 110 approved relational therapy hours?

YESNO

Based on the hours you have reported, you are at risk of not completing your clinical training hours requirement without adding at least one clinical extension course. The program strongly recommends that you discuss the possibility of adding additional sites with your assigned University Clinical Supervisor.

Please acknowledge the following the statements:

I am aware my hours are below the expected direct client contact and/or relational hours identified by the program.I understand the program strongly recommends that I speak with my University Clinical Supervisor about the potential need to add an additional site to complete my clinical requirements.I understand that I may need to take additional clinical extension courses if I do not meet the minimum clinical hours requirements to enter my capstone course.

MAMFT SUPERVISION Hours APPROVED in Clinical Tracking System

	Student: List APPROVED Hours ONLY	Faculty: Any Adjusted Hours	Admin: 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

Please upload the #523 Report - Approved Hours Log and the #514 Report (for co-therapy and specialization hour tracking) from Tevera.

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 and the CAT team can support you in selecting the appropriate course.

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, faculty, and the CAT 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 and CAT. 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

MFT 6934 CapstoneMFT 6935 the 4-week extensionMFT 6936 the 8-week extensionMFT 6937 the 12-week extension

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?*

YesNo

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

YesNo

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

I acknowledge that I, the student, 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.*

Yes, I acknowledge and understand the statement above

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?

YesNo

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?

YesNo

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

MFT 6934 CapstoneMFT 6935 the 4-week extensionMFT 6936 the 8-week extensionMFT 6937 the 12-week extension

Do students have the APPROVED hours to enter into Capstone?

YesNo

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

Did the student pass the Capstone draft?

YesNo

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

Course Enrollment Plan

Clinical Team Comments

Start Date of Clinical Experience

Date

Final Date of Clinical Experience

Date