Supervision Log Form
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1Supervision Log
Supervisor Name: ___________________________________________
License Type/Number:__________________
LPC Associate Name: ________________________________________
LPC (#________________)
This form is being provided as a sample log for use by NCBLPC Board Approved Supervisors. Supervisors
may develop their own form as long as the required elements as defined in Rule .0208 are documented on
the log. This form is not required to be provided to the NCBLPC Board unless formally requested.
Modality
Individual/Group
Direct/Indirect Hrs
Supervision Hrs
Dates – Start/Stop
Live
Co-Therapy
Audio Video
Group
Individual
/
/
_________________________________________________________
Notes:
(recommendation, interviews, etc.)
______________________________________________________________________________________
______________________________________________________________________________________
Individual/Group
Modality
Supervision Hrs
Direct/Indirect Hrs
Dates – Start/Stop
Live
Co-Therapy
Audio Video
Group
Individual
/
/
_________________________________________________________
Notes:
(recommendation, interviews, etc.)
______________________________________________________________________________________
______________________________________________________________________________________
Modality
Individual/Group
Dates – Start/Stop
Direct/Indirect Hrs
Supervision Hrs
Live
Co-Therapy
Audio Video
Individual
Group
/
/
/
/
_________________________________________________________
Notes:
(recommendation, interviews, etc.)
______________________________________________________________________________________
______________________________________________________________________________________
Individual/Group
Dates – Start/Stop
Direct/Indirect Hrs
Modality
Supervision Hrs
Live
Co-Therapy
Audio Video
Group
/
/
/ /
Individual
_________________________________________________________
Notes: (recommendation, interviews, etc.)
______________________________________________________________________________________
______________________________________________________________________________________
Important Reminders:
• A log of clinical supervision hours will be maintained that includes the date; supervision start and stop times; the modality of
supervision to be provided, such as live observation, co-therapy audio and video recordings, and live supervision, as defined by
Rule .0208; and notes on recommendations or interventions used during the supervision.
• The supervisor shall be available for consultation with the Board or its committees regarding the supervisee’s competence.
Supervision Log
Revised 09-24-14
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