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

VERIFICATION OF POST-INTERNSHIP SUPERVISION

Supervision Requirement, Public Law Chapter 386: A certificate holder (093) must be supervised for the first full school

year following the school psychology internship. The State Board of Education shall require evidence of supervision prior to

issuing the initial Three-Year Certificate. Supervision of the first year school psychologist must be in accordance with

supervision recommendations established by the National Association of School Psychologists (NASP) and provided by a

person who is employed or under contract as a certified school psychologist (see below).

For practitioners who have been in the field several years, there are two options for documenting post-internship

supervision:

Complete this form obtaining the signature of the appropriate supervisor;

Provide the Advisory Committee for School Psychologists with the original documentation/evaluation of

supervision signed by the supervisor and also using this form attest to the fact that the supervisor’s

qualifications are in accordance with the NASP Model (see below).

Name of applicant for 093 certificate (Supervisee): ________________________________

Name of School/Unit where supervised:

Age/Grade/Population Served:

Describe types of services provided:

Dates of Employment

Hours worked per week

Direct supervision hours per

Total hours under direct

week

supervision for year

How many hours did the applicant complete in each of the following areas?

Intervention: consultation, therapy, counseling, or other intervention

Psychological Assessment: cognitive, academic, or behavioral/emotional

Other Psychological Experience: supervision of others, program development, outcome assessment,

systems intervention, team/IEP meetings, research

Support Activities: case conferences; case management; training; progress notes; chart review;

psychological assessment scoring, reporting, and writing; record keeping

Assessment of Supervisee’s Performance:

__ Highest professional quality

__ Highest initial certificate holder quality, but not on par with fellow professionals

__ Adequate quality, on-going involvement in peer supervision recommended

__ Adequate/Marginal quality, recommend continued professional supervision*

__ Unacceptable level of performance*

__ Unacceptable functioning because of ethical or personal problems*

__ Highly Variable*

* Must be reviewed for further action by DOE Advisory Council for School Psychologists

Required Qualifications of Supervisor: Supervisors of school psychologists and supervisors of trainees should hold the

Nationally Certified School Psychologist credential or the school psychology credential for the state, and have at least three

years' experience as a school psychologist. Training and/or experience in the supervision of school personnel are desirable.

! I, the supervisor, certify that I meet the current NASP recommendations for qualifications of supervisors and that I

abide by current NASP ethical standards and practices for supervision of school psychologists.

! In addition, I, the supervisor of the above named supervisee, certify that the information provided on this form is

verifiable, factual, and accurate.

____________________________ _________________________________ _______________________ ___________

Supervisor Name

Supervisor Signature

Certificate/License Number

Date

_____________________________________________________ _____________________ __________________________

Address of Supervisor

Phone Number

School Psychologist (093) Certificate Page 11

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