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