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Congregational and Family Systems Academy
Our Therapists
Therapy
Individual Therapy
Couples Therapy
Family Therapy
Sex Therapy
Low Cost Therapy Services
Relationship Checkup
Therapy & Support Groups
Workshops
Our Programs
Community Partnerships Initiative
Child, Adolescent & Family Services
Community Trauma Response
Older Adults Program
Operation Home & Healing
Transcending Trauma Project
Women’s Psychological Health Services
Professional Education
CE Workshops
Clinical Internship Program
Clinical Supervision
Congregational and Family Systems Academy
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Monthly Clinical Hours Report
Use the form below to submit your clinical hours.
Questions? Reach out to Michelle Serious via
email
.
Clinician Name
(Required)
First
Last
Clinician Email
(Required)
Type
(Required)
Individual Supervision
Group Supervision
Supervisor Name - Individual
(Required)
Carol Blum
Bea Hollander
Dee Littleton
Peggy Roth
Michele Southworth
Noel Diorio
Tracey Tannenbaum
Priscilla Singleton
Charles Muorah
Laurel Roe
Ayo Akindumila
Darrell Carson
Kerstin Miller
Frani Pollack
Nina Fortuna
John McWilliams
Allen Lewis
Florda Priftanji
Lucy Raizman
Jamie Rose
Brittany Kurdewan
Susanne Flood
James Wadley
Sara Corse
Courtney Ragin
Kimberly Holt
Sarah Valdivieso
Lisa Handler
Margot Stein
Nina Fortuna
Susan Gordon
Alexis Bove
Supervisor Name - Group
(Required)
Carol Blum
Bea Hollander
Dee Littleton
Peggy Roth
Michele Southworth
Noel Diorio
Tracey Tannenbaum
Priscilla Singleton
Charles Muorah
Laurel Roe
Ayo Akindumila
Darrell Carson
Kerstin Miller
Frani Pollack
Nina Fortuna
John McWilliams
Allen Lewis
Florda Priftanji
Lucy Raizman
Jamie Rose
Brittany Kurdewan
Susanne Flood
James Wadley
Sara Corse
Courtney Ragin
Kimberly Holt
Sarah Valdivieso
Lisa Handler
Margot Stein
Nina Fortuna
Susan Gordon
Alexis Bove
Month/Year
(Required)
Client Hours
First Initial
Type of Client
Status of Case
Total Hours
Actions
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Entries.
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The totals below are automatically generated from Client Hour entries.
All Hours
Individual
Couple
GS - Group
GI - Group
Family
Offsite Location Identity
List any agencies for off-site clients.
Modality Report
Date of Supervision
Total
Actions
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Entries.
Add Entry
Maximum number of entries reached.
The totals below are automatically generated from Modality Report entries.
All Hours
Case Review
Audio
Video
Live
Confirmation
(Required)
By submitting this document, you are attesting to the accuracy of the information provided in this document.
