Supervised Experience Attestation Form-Fall 2013 - Florida Department Of Health
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1SUPERVISED EXPERIENCE ATTESTATION FORM
Print clearly or type the following information:
Applicant’s Name ___________________________________________Intern Registration No.___________________
Clinical Social Work
Marriage & Family Therapy
Mental Health Counseling
Supervisor’s General Information (to be completed by supervisor)
Supervisor’s Name:
Phone:
Address:
License/Certification
State
Original Licensure Date
License Number
Title
Other Professional
Organization
Original Certificate Date
Certification Number
Credential
Supervised Experience Affirmation (to be completed by supervisor)
I have read and understand Rule Chapter 64B4-2, F.A.C. I provided at least one (1) hour of supervision per fifteen
(15) hours of psychotherapy face-to-face with clients provided by the intern, with a minimum of one (1) hour of
supervision every two (2) weeks. Supervision was provided from
_______/_______/_________ to _______/_______/________ for a total of _____________ weeks.
The applicant provided psychotherapy face-to-face with clients for _____________ hours per week.
I intend to continue to provide supervision until the registered intern is fully licensed pursuant to Section
491.0045(3), Florida Statutes and Rule 64B4-3.008, F.A.C. If this status changes before the intern is fully
licensed, I will notify the board office in writing of the date I stopped providing supervision.
I am no longer providing this registered intern with supervision as of _________________________________
Month
Day
Year
Each blank line and one box in this section must be completed.
ONE BOX BELOW MUST BE CHECKED!
As a professional licensee overseeing the supervision of this intern, do you have any information regarding this
registered intern’s ability to practice and/or counsel independently? Please check one of the following that most
closely reflects your opinion as the supervisor overseeing the internship.
Has met the minimum standards of performance in professional activities when measured against generally
prevailing peer performance, pursuant to Section 491.009(1)(r), Florida Statutes.
Has not met the minimum standards of performance in professional activities when measured against generally
prevailing peer performance, pursuant to Section 491.009(1)(r), Florida Statutes.
If you have chosen “has not met”, you must provide further information as to why this requirement
has not been met.
_____________________________________________________________________________________________
Supervisor’s Signature (must be original signature)
Date
This form is to be COMPLETED (not just signed) by the SUPERVISOR!
Florida Department of Health
Florida Department of Health
Florida Department of Health
Florida Department of Health
Division of Medical Quality Assurance • Board of Clinical Social Work, Marriage and
TWITTER:HealthyFLA
Family Therapy and Mental Health Counseling
FACEBOOK:FLDepartmentofHealth
4052 Bald Cypress Way, Bin C-08 • Tallahassee, FL 32399-3258
YOUTUBE: fldoh
PHONE: 850/245-4474 • FAX 850/921-5389
DH-MQA 1181, 5/13
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