Clinical Supervision Plan Template
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4CLINICAL SUPERVISION PLAN
INFORMATION & INSTRUCTIONS
Submit Supervision Plans and Supervision Verification forms using
‘ONLINE SERVICES’ or ‘DOWNLOADABLE FORMS’ at the Board’s website
REVIEW BOARD STATUTE: Review supervised practice requirements at the Board of Social Work website.
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SUPERVISION PLAN REQUIRED: Supervision Plans must be submitted to the Board within 60 days of beginning a social work
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position. Submit a:
(1) revised plan within 60 days of a substantial change to your original plan;
(2) a separate Supervision Plan form for each social work position;
(3) one form for multiple supervisors submitted for the same position. Make copies of the supervisor page as needed.
COMPLETE FORM: Complete and KEEP ALL PAGES TOGETHER. Incomplete forms will be returned and will result in delayed
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processing.
DETAILED DESCRIPTION OF PRACTICE: Attach a detailed description of clinical practice according to the instructions on page
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three of this form. All supervisors must sign the detailed description of practice.
SUPERVISION PLAN LATE FEE: Supervision Plan late fee of $40 may be assessed at license renewal if the required Supervision
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Plan is not submitted within the 60-day deadline of beginning a social work position.
VERIFICATION REQUIRED: Supervision Verification form is required at license renewal, or when applying for either the LISW or
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LICSW, to demonstrate compliance with Supervision Plan.
TENNESSEN WARNING
The Board is seeking data from you which may be considered private or confidential under the Minnesota Government Data
Practices Act. Minn. Stat. sec. 13.04, subd. 2 requires the Board to notify you of the following four matters before you are asked to
supply such information: (1) This data is being collected to determine whether you have violated any statutes or rules the Board is
empowered to enforce and/or to determine whether you meet the requirements for licensure or renewal; (2) You are not legally
required to provide the information requested, but failure to do so may result in the denial of the licensure application, and/or
disciplinary or other action by the Board; (3) If you supply the data requested and it shows a violation of any of the statutes or
rules enforced by the Board, you may be subject to disciplinary or other action by the Board. In addition, falsification or omission
of information may be used by the Board as a basis for disciplinary action. (4) The data which you supply will be accessible to
Board staff and may also be released to other persons or governmental entities that have statutory authority to review the data,
investigate specific conduct, or take appropriate legal action, such as Board members and the Attorney General. If the Board
institutes a formal disciplinary action against you, the information you supply could become public.
LICENSEE/SUPERVISEE STATUS
I am submitting the following (check one):
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New supervisor
Additional supervisor
Type or amount of
supervision
REVISED PLAN (circle change)
INITIAL PLAN
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Employment
Scope of position
LICENSE NUMBER:
CURRENT LICENSE:
LGSW engaged in clinical social work practice
(check one)
LISW engaged in clinical social work practice
LAST NAME
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FIRST NAME:
MIDDLE NAME:
(as it appears on license card)
Minnesota Board of Social Work
Clinical Supervision Plan
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Parent category: Medical