Documentation Of Supervised Counseling Experience - New Jersey Page 3
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310. Counseling procedures implemented by supervisee: (See N.J.A.C. 13:34-10.2 and check all that are applicable.)
Appraisal and assessment
Counseling
Consulting
Referral
Research
11. supervisor’s conclusions and recommendations
This applicant is seeking to become a licensed professional counselor or a licensed rehabilitation counselor in New Jersey.
By this application, the applicant is claiming readiness for unsupervised, independent professional practice and readiness as
a clinical supervisor. In assessing the applicant’s professional readiness, you are now being asked if the applicant possesses
the following abilities and knowledge.
The ability to establish a counseling relationship.
Yes
No
Not observed
The ability to assess a client’s needs and to plan appropriate interventions.
Yes
No
Not observed
The ability to make interventions appropriate to client needs.
Yes
No
Not observed
The ability to be flexible in choosing and changing interventions as appropriate.
Yes
No
Not observed
The ability to assess prudently one’s own capacities and skills in a professional
situation.
Yes
No
Not observed
The ability to work effectively in a one-to-one relationship.
Yes
No
Not observed
The ability to work effectively where systems-level interventions are required.
Yes
No
Not observed
The applicant demonstrates ethical behavior.
Yes
No
Not observed
12. on a separate sheet of paper, please assess the applicant’s current state of preparedness for licensure. Also, please make
a recommendation regarding the applicant’s further professional development. Your recommendations are an
important element in the Committee’s overall evaluation of the applicant’s qualifications for licensure.
13. I recommend the applicant for licensure at this time.
I do not recommend the applicant for licensure at this time.
Certification
I certify that all of the foregoing information provided herein is true and if any information provided by me is willfully false,
I am subject to punishment.
________________________________________________________ _______________________________________
Signature of supervisor Date
Comments: ____________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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