Name:____________________________ Date:    
Time Worked: Start Time:   Ending Time:  
Total Time Worked Per Function Total Time Worked Per Function
Screening:   Case Management:  
Intake:   Crisis Intervention:  
Orientation:   Client Education:  
Assessment:   Referral:  
Counseling:   Report & Record Keeping:  
Treatment Planning:   Consultation:  
Time Worked: Start Time:   Ending Time:  
Total Time Worked Per Function Total Time Worked Per Function
Screening:   Case Management:  
Intake:   Crisis Intervention:  
Orientation:   Client Education:  
Assessment:   Referral:  
Counseling:   Report & Record Keeping:  
Treatment Planning:   Consultation:  
Time Worked: Start Time:   Ending Time:  
Total Time Worked Per Function Total Time Worked Per Function
Screening:   Case Management:  
Intake:   Crisis Intervention:  
Orientation:   Client Education:  
Assessment:   Referral:  
Counseling:   Report & Record Keeping:  
Treatment Planning:   Consultation:  
     
Supervisor Signature Date