School Psychologist (093) Certificate (Page 10 of 11) in pdf

School Psychologist (093) Certificate Page 10

SCHOOL PSYCHOLOGIST SUPERVISION AGREEMENT FORM

Name

Home phone

Mailing Address

Work phone

Town

Cell Phone

State

Date

ZIP

Supervisor Name

My signature below verifies that I have contracted to participate in 1,500 supervised hours between the dates of

____________ and ___________. I understand that I am responsible for accuracy in reporting my supervised

hours and that reporting inaccurate supervision hour completion is a violation of NASP and APA ethical

guidelines. I understand that inaccurate reporting is grounds for denial of the School Psychologist Certificate.

__________________________________________________________

______________

Signature

Date

The following signatures verify that the school psychologist named above has contracted with me for completion

of 1,500 supervised practice hours toward fulfillment of the supervision requirement for a certificate in school

psychology (093).

___________________________________________________________

______________

Supervisor Signature

Date

Supervisor credentials:

___ Licensed Psychologist (state:______ number:_______ expiration date:_________)

___ Nationally Certified School Psychologist number: _________ expiration date:_________)

___ Certified School Psychologist (state:______ number:_______ expiration date:_________)

School Psychologist (093) Certificate Page 10