Fillable Form #7: Intern Supervised Clinical Experience Plan (Page 4 of 4) in pdf

REGISTERED INTERN AGREES TO:



Abide by the Code of Ethics for Counselors and Therapists as specified in OAR 833, Division

100 and Oregon law and rules for LPCs and LMFTs.



Distribute Professional Disclosure Statements to clients at the onset of therapeutic services.



Establish and maintain a record keeping system to track the direct client contact and

supervision hours.



Submit requests to change or modify the “Work Plan” to Board prior to implementing changes.



Ensure supervisor has authority to review all records, determine appropriateness of records,

direct referrals of inappropriate clients, determine caseload, and report to Board.

TERMINATION OF INTERN REGISTRATION

Approval of this Plan may be terminated for failing to obtain prior approval of the Board for changes in

plan terms: place of practice[s]; supervisor[s], including license/certification status; and level of

supervision.

Registration as an intern may be terminated for the following reasons



Failure to file a replacement plan within 90 days of the termination of supervisor.



Failure to file a replacement plan within 90 days of the termination of a place of

practice/employment.



Failure to submit a Registered Intern Six-Month Supervisor Evaluation & Hours Report.



Failure to notify or file a replacement plan after placing internship on a 90-day hold.



Failure to renew registration.



Voluntary resignation or withdrawal of application.



Exceeding five years from initial date of registration.

CERTIFICATION / SIGNATURES

I certify that the information provided in this document is true and correct to the best of my knowledge. I

agree to follow the provisions set forth in this plan. I understand my responsibilities. I understand that

knowingly making a false statement in connection with this proposed plan may result in disciplinary

action. I have been given a copy of this Intern Supervised Work Plan, Pages 1 - 4.

______________________________________________________ _________________________

Signature of Applicant

Date

_____________________________________________________

__________________________

Signature of Clinical Supervisor

Date

Instructions for Submitting Completed Form



Provide copies of this form for all signatories.



Submit this form, with original signatures and a Professional Disclosure Statement for each

work location.



Mail to: Oregon Board of Licensed Professional Counselors & Therapists, 3218 Pringle Rd SE,

#250 Salem, OR 97302-6312

For Board Use Only

Effective Date: ______/_______/_______.

End Date: _____/_____/______.

Registration No:

_________ Board approval: ________________________________________

Intern Clinical Experience Plan

Page 4 of 4

Form #7: Intern Supervised Clinical Experience Plan Page 4

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