Form #7: Intern Supervised Clinical Experience Plan
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4Oregon Board of Licensed Professional Counselors & Therapists
FORM #7: INTERN SUPERVISED CLINICAL EXPERIENCE PLAN
As part of your Initial Application, attach a Professional Disclosure Statement (PDS) for each
employer/practice. Plans will not be approved until the PDS(s) are received.
For Intern Plan Change Requests, adding or removing supervisors, attach a revised Professional
Disclosure Statement for each employer/practice.
Applicant/Intern Name: ____________________________________
LPC intern
LMFT intern
1. SETTING – Location(s) applicant/intern’s employer/practice site:
LOCATION 1
Agency Name:
Location Address:
Mailing Address or PO Box:
City / State / Zip:
Telephone:
E-mail:
LOCATION 2
Agency Name:
Location Address:
Mailing Address or PO Box:
City / State / Zip:
Telephone:
E-mail:
2. SUPERVISION REQUIRED
Supervision is required every month. The minimum level of supervision depends on the number of hours
accrued in a month. If the number of client contact hours in any given month is less than 46 hours, then the
minimum supervision requirement is two (2) hours, with a minimum of one (1) hour of individual supervision.
If the number of client contact hours in any given month is 46 hours or more, then the minimum supervision
1/2
requirement is three (3) hours of supervision, with a minimum of one and a half (1
) hours of individual
supervision. You can exceed the minimum level of supervision per month. If you do not meet minimum
monthly supervision requirements, then the client contact hours for the month will not be approved.
Provide a brief description of clients and counseling activities to be performed. Activities must include
assessment, diagnosis and treatment of your clients:
_________________________________________________________________________________
Intern Clinical Experience Plan
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