Supervision Agreement Form

*Some of the information below may not be applicable or appropriate for your state. One of the primary objectives of this agreement is to define respective roles and convey to your supervisor the seriousness of having or pursuing a license to practice psychotherapy. Modify the agreement as neccessary.*

Thank you for selecting me as your supervisor. If you commit to this learning process, I am sure you will find your experience with me to be uniquely helpful in your pursuit of a rewarding career as a professional counselor.

General Agreement:

You have been issued a license to practice professional counseling in _______. Your provisional license is a privilege, not an entitlement. You and I have the same privileges under our licenses with the exception that during any period of active practice, you must be under both direction and supervision simultaneously. You have agreed to abide by all applicable laws and rules that govern your license. If you fail in your agreement with the Licensing Board, it may ask you to account for these actions through a complaint or other processes. We are bound by the same code of ethics, which states our primary responsibility is to our clients. As your supervisor, my primary responsibilities are to train and teach you for the purpose of promoting professional development. Your responsibilities include submitting to training and following my recommendations.

As a trainer and teacher, I will provide you with clinically appropriate interventions for any of your clients. It is incumbent upon you to implement them. In some situations, there will be a conflict between my recommendations and the policies of the organization that employs you. This is especially true when they are not your clients but are clients of that organization. Difficult work situations could require you to make decisions about your employment in order to protect your license.

You are responsible for maintaining your practice license, including but not limited to ethics, renewal, fees, and continuing education requirements. I will assist you in all manners possible to achieve what is outlined in this paragraph.

Board Law and Rules:

I will review with you both the state mental health professional law and rules relevant to the practice of professional counseling. As a license holder, you are responsible for understanding both and obtaining clarification if necessary. There are many areas of the rules and laws where I can promote your understanding. Nonetheless, it is often not possible for licensees or the public or me to interpret either the Board Rules or our practice law as the board has discretion and is the sole enforcement entity and can change how it enforces a section of the rule or law. In these instances, you will need to obtain clarification directly from the board.

Consent for Telehealth:

You are required to obtain consent from your clients to deliver counseling via telehealth. This consent should include that confidential communication will be transmitted and stored electronically and on a remote server, and that it complies with federal HIPAA laws.

Important Legal Issues Not Specifically Addressed in Practice Law:

Whereas board ethics addresses professional considerations and obligations to peers, our communications are not legally protected in the same manner as therapist/patient. Specific patient information and their identities are legally confidential. It is a felony in Georgia to commit a sexual offense against a patient. This law can be found under GA Code Title 16 Chapter 6, "Sexual Offenses". It is important to note that the definitions are stated broadly to include various forms of physical contact. For clarification on these and other applicable laws, you will need to consult with an attorney. I encourage you to establish a relationship with an attorney as part of your professional practice, as they can represent you in the event of a civil suit and handle other business matters for you.

Peer Consultation:

I may discuss my supervision of you with other supervisors for consultation purposes. I will do this in a manner that conceals your identity.

Case Review:

I will need to review some of your cases and documentation for purposes of teaching.

High Risk Situations:

You are a mandatory reporter of child/ elder abuse. We will discuss situations that may require mandatory reporting, but if you suspect a case of abuse, make the report directly to Child or Adult Protective Services. You do not need proof of abuse. You only need to suspect it, and it is the state's responsibility to investigate. Situations may develop throughout the course of your work that I may decide should be taken out of the privacy of our relationship.

Evaluation:

I will provide you with both written feedback and verbal feedback. This feedback is intended to monitor your progress, modify our supervision plan, and serve as an aid to your learning.

Record of Supervision:

The board requires that both supervisee and supervisor maintain a contemporaneous record of dates and the length of supervision hours. Please do this, and I will do the same in the event the Board requests this information. I will also keep notes of your sessions and must submit them to the board upon request.

Filing a Board Complaint:

Any member of the public may file a board complaint against an individual licensed by the boards that regulate healthcare and other professional practice, including the Composite Board of Professional Counselors, Social Workers, and Marriage and Family Therapists. The Secretary of State’s webpage provides instructions for filing a complaint should you opt to pursue this.

After Hours Assistance:

Should you need urgent assistance with a case between sessions, contact me by telephone. I will make a determination to intervene with you directly, refer you to your agency, or clarify if it can be handled at our next supervision session.

Malpractice Insurance:

You are required to carry malpractice insurance. Please provide me a copy of the policy facesheet.

Other Supervisor and Directed Experience Documentation:

I will need copies of all past and present directed experience and supervisor forms.

Fees and Business Agreement:

If you must cancel a supervision session, please notify me within 24 business hours; otherwise, you will incur a late-cancellation fee equal to your hourly supervision fee. Either of us can terminate supervision at anytime. I will notify the board if either you or I terminates supervision. We will agree on fees for my supervision in advance. This shall be agreed upon in a separate document.

I look forward to working with you. Kindly, Jennifer Finch, M.A., LPC, NCC, SEP

PLEASE SIGN AND COMPLETE THE ELECTRONIC FORM BELOW TO ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTAND THE INFORMATION AND TERMS DESCRIBED HEREIN AND THAT YOU HAVE DISCUSSED WITH ME ANY PART OF THE INFORMATION YOU DO NOT UNDERSTAND.

THE ORIGINAL COPY OF THIS DOCUMENT WILL REMAIN IN MY FILE. FOR A PERSONAL COPY, YOU ARE RESPONSIBLE FOR PRINTING ON YOUR OWN.

“I FURTHER UNDERSTAND THAT SUPERVISION WITH JENNIFER FINCH DOES NOT IMPLY OR GUARANTEE THAT THE STATE WILL ISSUE MY PRACTICE LICENSE. I AM ULTIMATELY RESPONSIBLE FOR ALL ASPECTS OF OBTAINING AND MAINTAINING MY LICENSE.”