Form #7: Intern Supervised Clinical Experience Plan Page 2
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43. CLINICAL SUPERVISOR INFORMATION -- TO BE COMPLETED BY PROPOSED SUPERVISOR
Supervisor:
Name:
Business Address:
Phone:
E-mail:
Supervisor’s Mental Health Graduate Degree(s):
School:
Degree:
Issued
School:
Degree:
Issued
How long have you known the applicant/intern?
years
months Describe pre-existent relationship.
_____________________________________________________________________________________
Are you related to the applicant/intern?
Yes
No
Have you ever been disciplined by any regulatory board?
Yes
No
If applicant/intern is seeking registration as a MFT intern, please list graduate-level training in systemic
theory and approach to couples and families issues:
______________________________________________________________________________________________________
Supervisor’s Clinical Experience in counseling or marriage & family therapy:
Number of years licensed in Oregon:
_____
Approved Supervisor/Candidate on the OBLPCT Supervisor Registry (LPC/LMFT only):
Yes
No
Supervisor’s State License / National Credential:
License Title
Issued by [state or national org.]
License No
Original issue
Expiration date
date
License Title
Issued by [state or national org.]
License No
Original issue
Expiration date
date
Intern Clinical Experience Plan
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Parent category: Medical