PRSS Supervisor Form

SUPERVISION-To be completed by the supervisor.

Supervisor: Please complete this form indicating the applicant's on-the-job supervision. This form is not intended to document the applicant's total number of hours worked but rather the hours of on-the-job supervision you have provided the applicant.

Supervision is a formal or informal process that is administrative, evaluative, clinical, and supportive. It can be provided by more than one person; it ensures quality of care and extends over time.

Supervision includes observation, mentoring, coaching, evaluating, inspiring, and creating an atmosphere that promotes self-motivation, learning, and professional development. In all aspects of the supervision process, ethical and diversity issues must be in the forefront.
Applicant's Full Name
I hereby attest that a minimum of 30 hours of supervision in the domains have been attained by the above-named applicant. At least 6 hours in each of the domains were received as outlined below.

(Minimum of 6 hours in each domain)
1 Advocacy
2 Mentoring Education
3 Recovery Wellness Support
4 Ethical Responsibility
Harm Reduction
TOTAL MUST BE AT LEAST 30 HOURS
Supervisor's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Supervisor's Name Including Credentials or Licenses
Jan Doe, LPC, PRSS_SUD/MH etc..
Supervisor's Email
example@example.com
Should be Empty: