Clinical Supervision Plan Template Page 3
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4• SUPERVISOR #: ______ •
This section must be completed by your supervisor.
You may make copies of this page as needed to document additional supervisors.
SUPERVISOR INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE NAME:
LICENSE TYPE:
LICENSE NUMBER:
PHONE NUMBER:
EMAIL ADDRESS:
SUPERVISION PLAN HOURS PER MONTH
Report number and type of hours provided per month below.
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Group supervision is limited to 6 supervisees.
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For complete information regarding the clinical supervised practice requirements, reference the Board’s website.
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ONE-ON-ONE SUPERVISION (hours per month)
OTHER SUPERVISION (hours per month)
IN-PERSON:
ONE-TO-ONE PHONE:
EYE-TO-EYE
GROUP:
ELECTRONIC MEDIA:
TOTAL SUPERVISION HOURS PER MONTH:
CERTIFICATION OF SUPERVISOR
If you answer “NO” to any question below, include a detailed explanation (attach additional sheets if necessary).
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1. I attest that I have read, understand, and agree to comply with the supervised practice requirements for
YES
NO
licensure under Minnesota Statutes sections 148E.100 through 148E.125
2. I attest that this plan will be carried out as described.
YES
NO
3. I attest that the content of the supervision will include clinical practice, ethical standards of practice,
YES
NO
practice methods, authorized scope of practice, and continuing competence.
4. I attest that the detailed description of clinical practice is accurate.
YES
NO
5. ONLY SUPERVISORS LICENSED AS SOCIAL WORKERS IN MINNESOTA: I attest that I have completed a
YES
NO
N/A
one-time requirement of 30 hours of training in supervision.
6. ONLY ALTERNATE SUPERVISORS: I attest that I am a licensed mental health professional qualified to
YES
NO
N/A
provide supervision according to my licensing board.
ATTESTATION OF SUPERVISOR
1. I affirm: (1) I will directly supervise the licensee/applicant as outlined in this plan; (2) the information provided is true and
correct to the best of my knowledge; and (3) I understand that this information will be used to evaluate the supervisee’s
compliance with supervised practice requirements.
2. I will submit a Supervision Verification form at the supervisee’s license renewal and/or when the supervisee applied for
another license category.
SIGNATURE OF SUPERVISOR:
DATE:
LICENSEE/SUPERVISEE NAME & LICENSE NUMBER: ________________________________________________________
Minnesota Board of Social Work
Clinical Supervision Plan
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