CS Supervisor Supervision Verification Form

CS Supervisor Supervision Verification Form

Supervisor attestation of applicant’s face-to-face clinical supervision hours provided to counselors.
TO THE SUPERVISOR: Please complete this form indicating this applicant’s on the job supervision in providing clinical supervision. This form is not intended to document applicant’s total number of hours worked but rather the hours of face-to-face supervision this applicant has provided to counselors.I hereby attest that a minimum of 200 clock hours of face to face or live synchronous supervision in the following performance domains have been provided to counselors by the above named applicant as outlined below. Do NOT include PRSS Supervison hours.
Applicant’s Name
Counselor Development - Hours Provided
Professional and Ethical Standards - Hours Provided
Program Development and Quality Assurance - Hours Provided
Assessing Counselor Competencies and Performance - Hours Provided
Treatment Knowledge - Hours Provided
Total Supervision Hours
Supervisor Signature
Supervisor Print Name
Date

MonthDayYear
Date
Should be Empty: