Documentation Of Supervised Counseling Experience - New Jersey Page 2
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33. Graduate school attended: ___________________________________________________________________________
Major: _ _____________________________________Highest degree earned: __________________________________
4. Is there any circumstance that precludes your objective assessment of the applicant?
Yes No
If “Yes,” please explain on a separate sheet of paper. N.J.A.C. 13:34-13.1(l) (Examples: current and former clients,
current employers (employees may not supervise employers), relatives of the supervisor, relatives of current clients,
current students or close friends.)
the information requested below concerns the setting in which the applicant received his or her supervised experience.
____________________________________________________________ Tax status:
for-profit
not-for-profit
Name of setting
____________________________________________________________________________________________________
Street address
City
State
ZIP code
Telephone number (include area code)
1. Applicant’s title (if any) during the time I supervised him or her: _ ____________________________________________
2. Inclusive dates of the supervision: _______________________________
__________________________________
Date supervision started
Date supervision ended
(See N.J.A.C. 13:34-10.2, “One Calendar Year” means a maximum of 1,500 hours/year, 125 hours/month, 30 hours/week.)
3. Total number of supervised counseling or rehabilitation counseling hours completed by the applicant under my
supervision: ___________________
4. Average number of hours per week I spent with the applicant in face-to-face supervision: __________
5. Average number of hours per week I spent with the applicant in group supervision: ____________
6. I performed at least one of the following activities throughout the course of supervision. Check all that apply.
(See N.J.A.C. 13:34-13.1(d)1)
I worked as a co-counselor with the applicant.
I observed the applicant’s sessions with clients.
I viewed videotapes of the applicant’s sessions with clients.
I listened to audiotapes of the applicant’s sessions with clients.
7. I performed at least one of the following activities throughout the course of supervision. Check all that apply.
(See N.J.A.C. 13:34-13.1(d)2)
I reacted to case presentations given by the applicant.
I conducted role-playing sessions with the applicant.
8. I performed all of the following activities throughout the course of supervision. Check all that apply.
(See N.J.A.C. 13:34-13.1(d)3)
I engaged in problem-solving discussions with the applicant regarding individual clients.
I entered into problem-solving discussions concerning the applicant’s own problems, insofar as such problems were
affecting the applicant’s work with clients.
I offered feedback to the applicant regarding specific interventions utilized with a client.
I offered feedback concerning the applicant’s personal qualities as they affect work with clients.
I offered feedback to the applicant regarding the supervision experience.
Other (please be specific) ________________________________________________________________________
__________________________________________________________________________________________
Did you maintain weekly supervision notes which will be made available to the Committee upon request?
Yes No
9. services provided by supervisee: (See N.J.A.C. 13:34-10.2 and check all that are applicable.)
Clinically assess and evaluate mental, emotional, behavorial and associated distresses
Conduct assessments and evaluations for the purpose of establishing treatment goals and objectives
Plan, implement and evaluate counseling interventions
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