Clinical Supervision Session Form

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Clinical Supervision Session Form 
 
Name of Supervisee: 
□ Online               □ Telephone  
Mode of clinical oversight:      
 
                                                □ Telemedicine   □ In person             
    □ Individual     □ Group 
Please indicate: 
Date of session: 
Duration of session:  
 
(Telephonic sessions must be at least 30 minutes) 
Comprehensive description of topics discussed: 
 
 
 
 
 
Comprehensive description of results of compliance review of supervisee’s clinical documentation: 
 
 
 
 
 
Does any conflict of interest exist between supervisor and supervisee?     ⃝   Yes            ⃝   No 
Does any conflict of interest exist between supervisee and clients?            ⃝   Yes            ⃝   No 
All sections above must be completed in their entirety. Refer to R4‐6‐212 F4 a‐e. 
Supervisor’s name and credentials:  ________________________________________ 
Supervisor’s telephone number:  ______________________________ 
 
________________________________________________________                ______________________ 
                                             Supervisor signature                                                                       Date signed 
 
________________________________________________________                ______________________ 
 Supervisee signature                                                                       Date signed 
Clinical Supervision form effective 04/04/14 
 

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