Supervisee'S Clinical Supervision Log Template With Notes
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1Supervisee’s Clinical Supervision Log & Notes
Supervisee Name: _______________________________
Date: ____________________
CLINICAL Supervisor Name: _______________________________
Meeting #: ______
:
Agenda for session
(i.e. client review, documentation, research, treatment techniques, etc.)
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Client Identifier: ______
Demographics:
New Client
or
Update
(i.e. age, ethnicity, etc.)
Presenting Issue:
Treatment Modality Utilized:
Individual
Family
Couple
Group (no more than 6 per group)
Theoretical Approach:
NOTES:
Interventions Utilized:
Treatment Plan:
Suggestions/Follow-Up:
Client Identifier: ______
Demographics:
New Client
or
Update
(i.e. age, ethnicity, etc.)
Presenting Issue:
Treatment Modality Utilized:
Individual
Family
Couple
Group (no more than 6 per group)
Theoretical Approach:
NOTES:
Interventions Utilized:
Treatment Plan:
Suggestions/Follow-Up:
Supervisee Signature: _________________________________________
Date: _________________
CLINICAL Supervisor Signature: _________________________________________
Date: _________________
Disclaimer: Use of this form does hereby RELEASE, WAIVE and FOREVER DISCHARGE any and all claims arising out of, or in connection with, such use of this LPCA
form, including without limitation any and all claims for libel or invasion of privacy.
Original created 1-4-2017
Revised 01-10-17
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Parent category: Medical