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Neuropsych AssessmentDaily Log of Practicum Hours Student: Site: Date: Time IntervalHours Client ID#,Activity (as discussed in APPIC Application)TotalmNumber of Diverse Clients Seen Semester/YR ____________________________________:< A Student Name _______________________________________________Q SiteName/ Type ______________________________________________________________ Total ClientsDIVERSITY OF CLIENTS SEENRace/ Ethnicity'African American/ Black /African Origin*Asian-American/ Asian Origin/ Pacific Isl.Latino-a/ HispanicEuropean Origin/ WhiteBi-racial/ Multi-RacialOtherSexual Orientation HeterosexualGayLesbianBisexual DisabilitiesPhysical/ OrthopedicBlind/ Visually ImpairedDeaf/ Hard of HearingLearning/ Cognitive DisabilityGenderMaleFemale[Number of Tests Administered - Practicum Semester/YR ______________________.37 Student Name _______________________________________________ Supervisor's Signature __________________________r SiteName ____________________________________________________ Date _____________________________B Type of Site ___________________________________________________ Date Client Assessment Date Scored Date Report IntegrativeAssessedWrittenReportSerious Mental Illness 1. Supervision of other students 2. Program Development/Outreach 5. Consultation3. Supervision Received6A. Hours spent in one-on-one, face-to-face supervisionTOTAL SUPERVISION HOURS 1. Adults$G. Other Psychological Interventions&1. Sport Psych/Performance Enhancement'2. Medical/Health-Related Interventions)I. Other Psych Exp with Students &/or Org 5. Other 3American Indian/ Alaska Native/ Aboriginal CanadianRevised 9/14/073Date ______________________________________________6Supervisor's Signature _______________________________TOTAL APPIC HOURS$TOTAL INTERVENTION/ASSESSMENT (A-I) 1. Intervention Experience2. Adolescents (13-17)3. Children (12 and under)2. Support Activities (Case Conf, Case Mgmt/Cons, Didactic Train/Seminars/Grnd Rnds, Progress Note/Clinical Wrtng /Chart Rev, Psych Assess Scoring/Interpret. Video-Audio-Digital Recording Review)*3. Outcome Assessment of programs/projects74. Systems Intervention/Org. Consult./Perf. Improvement&i. Provided by Licensed Psychologist;ii. 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