Form08 - [FORM 8-Use the top of this page for your...

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[ FORM 8 —Use the top of this page for your letterhead.] Agreement for Professional Supervision Services Introduction This agreement has been created to address the legal, ethical, practical, and clinical issues of the supervision relationship. It can be added to or modified as the supervision process unfolds over time and across cases, and these addenda are indicated on the last page. This agreement is intended to articulate and clarify the complex mutual responsibilities of the parties involved, the procedures of the supervision, and the personal development needed to become a capable and responsible professional (deserving of independent professional practice). Parties We, , (hereinafter called the “supervisee”) and (hereinafter called the “supervisor”), agree that the supervisor will provide professional supervision services as outlined below. Meetings and communication The supervisee agrees to meet with the supervisor in person as mutually arranged or at these locations and times: Location Days, hours Location Days, hours It is the supervisee’s responsibility to initiate meetings as often as necessary to meet the goals of supervision, to meet his or her training needs, provide high levels of care to the clients involved, and to address other needs that may arise. Besides our face-to-face meetings, we may use postal mail, telephone, video, e-mail, or other means to communicate. If we use e-mail messages or wireless phones to discuss cases or other confidential information, they must be encrypted. Electronic recordings will require the written consent of the clients involved. Because we need to be able to reach each other easily and because emergencies may arise, the following arrangements for contact are made. Supervisee Days and hours of availability Means of emergency contact Days and hours of availability Means of emergency contact Days and hours of availability Means of emergency contact FORM 8. Agreement for professional supervision (p. 1 of 4). Incorporates some ideas from a form devised by Kathleen Quinn, EdD, of Cheyenne, WY, and used by permission of Dr. Quinn.—From The Paper Office . Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details). (cont.)
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Supervisor Days and hours of availability Means of emergency contact Days and hours of availability Means of emergency contact Days and hours of availability Means of emergency contact When the supervisor is unavailable due to vacation or other events, the supervisor will assure adequate availability of a substitute supervisor and will inform this person of the supervisee’s needs and situation. Frequency and Financial Concerns The supervisee agrees to pay for services provided, up until the time either of us informs the other (in person or by written means) of his or her plans to end the relationship. The supervisee agrees to pay the fee of $ per session for these services, starting on or about and continuing at about the rate of about
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This note was uploaded on 07/01/2010 for the course COUN 6682 A and taught by Professor All during the Spring '10 term at Walden University.

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Form08 - [FORM 8-Use the top of this page for your...

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