Form Bol - Psy-Se-1 - Application To Supervise A Psychology Service Extender Form (Page 2 of 3) in pdf

APPLICATION TO SUPERVISE A PSYCHOLOGY SERVICE EXTENDER

(continued)

PLAN FOR SUPERVISION ADDENDUM

My plan for supervising the service extender includes the following:

1. Frequency of face-to-face one-to-one supervisory sessions_______________________________________________________

2. Length of face-to-face one-to-one supervisory sessions__________________________________________________________

3. Frequency of face-to-face group supervisory sessions___________________________________________________________

4. Length of face-to-face group supervisory sessions______________________________________________________________

5. My plan for chart review, including frequency & nature of review, is as follows: _____________________________________

______________________________________________________________________________________________________

6. My plan for tape review, including frequency & nature of review, is as follows: ______________________________________

______________________________________________________________________________________________________

7. Number of service extender client contact hours per week _______________________________________________________

8. During the performance of the service extender's duties I will be regularly present on site for a minimum of __________ hours.

9. My written record of all supervisory sessions, including the amount of time I was available on site while the service extender was

performing duties and how I determined that time, will be maintained as follows: ____________________________________

______________________________________________________________________________________________________

10. I have attached additional information which may assist the Board in evaluating your application.

[ ] Yes

[ ] No

(Please list additional documentation below)

_____________________________________________________________________________________________________

BOL – PSY-SE-1 - revised 02/00

Form Bol - Psy-Se-1 - Application To Supervise A Psychology Service Extender Form Page 2