Clinical Supervision Plan Template Page 2
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4CONTACT INFORMATION
You MUST provide a PUBLIC address and a MAILING address, and a PUBLIC phone number and a PRIMARY phone number, which
can be the same or different.
PUBLIC address and PUBLIC phone: Classified as public data and available to any person upon request. If this information is not
•
provided, your application is void and will be returned to you.
MAILING address: Used to send all Board correspondence. If a mailing address different than the public address is not
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designated, all correspondence will be sent to the public address.
PRIMARY phone: If not specified, the public phone will be designated as the primary phone.
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PUBLIC ADDRESS
:
TYPE
:
(required)
(check one)
Home
CITY:
COUNTY:
STATE:
ZIP CODE:
Business
Other
MAILING ADDRESS
:
TYPE
:
(optional, provide if DIFFERENT than public address)
(check one)
Home
CITY:
COUNTY:
STATE:
ZIP CODE:
Business
Other
PUBLIC PHONE
(required)
:
TYPE
(check one)
:
Business
Home
Mobile
Fax
Other
PRIMARY PHONE
:
(optional, provide if DIFFERENT than public phone)
TYPE
:
(check one)
Business
Home
Mobile
Fax
Other
EMAIL ADDRESS
(optional, classified as public data)
:
EMPLOYMENT INFORMATION
If you have more than one social work position, submit a separate Supervision Plan form for each position.
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EMPLOYER NAME
:
(no acronyms)
POSITION:
START DATE:
END DATE:
(mm/dd/yyyy)
(mm/dd/yyyy)
TYPE
:
STREET ADDRESS:
(check one)
Home
CITY:
COUNTY:
STATE:
ZIP CODE:
Business
Other
SUPERVISION START DATE:
AVERAGE NUMBER OF HOURS
(mm/dd/yyyy)
WORKED PER WEEK:
ATTESTATION OF LICENSEE/SUPERVISEE
1. I attest that I have read, understand, and agree to comply with the supervised practice requirements for licensure under
Minnesota Statutes sections 148E.100 through 148E.125.
2. I attest that this plan will be carried out as described.
3. I understand my licensing supervisor must complete the ‘Supervisor’ section(s) before submitting the complete form to the
Board office.
SIGNATURE OF LICENSEE:
DATE:
LICENSEE/SUPERVISEE NAME & LICENSE NUMBER: ________________________________________________________
Minnesota Board of Social Work
Clinical Supervision Plan
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