Clinical Supervision Agreement

Supervisee Name & Degree: _____________________________________________________

 

Site Name: ____________________________________________________________________

 

This document is intended as informed consent for supervision.  The purpose is to establish parameters of clinical supervision, assist in supervisee professional development, and provide clarity in supervisor responsibilities including the responsibility of both the supervisor and trainee.  The goal is to help trainees obtain the assistance they need throughout the year in a manner that provides them with quality training and provides the best services to the clients.   

 

Supervisors:

 

Primary Supervisor (Name, Degree | Title):

 

______________________________________________________________________________

 

Auxiliary Supervisor (Name, Degree | Title):

 

______________________________________________________________________________

 

Connections Internship Consortium Training Director:

 

Kathryn J. Hefferon, Psy.D. | Clinical Psychologist

 

 

  1. Competency Expectations

    1. Supervision will occur in a competency-based framework.

    2. Supervisees will self-assess clinical competencies (knowledge, skills, and values/attitudes)

    3. Supervisors will compare supervisee self-assessments with their own assessments based on observation and report of clinical work, supervision, and competency-instruments.

 

  1. Context/Procedural Aspects of Supervision

    1. _____hour(s) of individual supervision per week.

    2. _____hour(s) of group supervision per week

    3. Review of therapy progress notes

    4. Supervision will consist of multiple modalities including review of audio/video tapes, progress notes, discussion of live observation, instruction, modeling, mutual problem solving, and role-play.

    5. Supervision is not a confidential relationship.  The supervisor is both a supervisor and administrator.  As such, information obtained in supervision may be shared with other administrators and/or the supervisee’s graduate program training department, if deemed appropriate by the supervisor.

    6. Progress reports will be submitted to your home doctoral program, if applicable, describing your development, strengths, and areas of concern.

    7. If the supervisor or the supervisee must cancel or miss a supervision session, every attempt will be made to reschedule the supervision, or provide an opportunity to meet with another supervisor.

    8. The supervisee may contact the supervisor at (contact #) ______________________.  The Supervisee may contact a secondary supervisor at (contact #) __________________.  The supervisee may contact Dr. Hefferon at 773-991-3016.  A supervisor must be contacted for all emergency situations.

    9. Interns may also receive supervision from a Post-Doctoral Fellow /other Program Therapist.  Any unlicensed trainee from whom you receive supervision will receive supervision on their supervision of your work. Your primary supervisor will discuss with you how that supervision is proceeding. 

 

  1. Evaluation

    1. Feedback will be provided on an ongoing basis. Feedback is related to competency benchmarks.

    2. Summative evaluation will occur at 2 intervals per year (mid-year and final evaluation)

    3. Forms used in summative evaluation are available on the team drive and from the CIC Training Director.

    4. The supervisor signs off on the supervisee’s supervision notes, and uses these to evaluate supervisee’s understanding, retention, and follow through of supervision feedback.

    5. The training site maintains a Due Process and Grievance policy, and this policy will be explained during the initial orientation process to all supervisees.

 

  1. Duties and Responsibilities of Supervisor(s)

    1. Upholds and adheres to APA Ethical Principles of Psychologists and Code of Conduct

    2. Oversees and monitors all aspects of client case conceptualization and treatment planning

    3. Provides live supervision at least once per evaluation period and additionally as needed

    4. Assists in development of goals and tasks to achieve in supervision specific to assessed competencies

    5. Challenges and problem-solves with supervisee

    6. Provides interventions with clients and directives for clients at risk

    7. Identifies theoretical orientation(s) used in supervision and in therapy and takes responsibility for integrating theory in supervision process, assessing supervisee theoretical understanding/ training/ orientation(s)

    8. Identifies and builds upon supervisee strengths as defined in competency assessment

    9. Introduces and models use of personal factors including belief structures, worldview, values, culture, transference, countertransference, and parallel process in therapy and supervision

    10. Ensures a high level of professionalism in all interactions

    11. Raises issues or disagreements that may impact the supervision process to move towards resolution

    12. Signs off on all supervisee case notes

    13. Clearly distinguishes and maintains the line between supervision and therapy.

 

  1. Duties and Responsibilities of the Supervisee

    1. Upholds and adheres to APA Ethical Principles of Psychologists and Code of Conduct

    2. Participates in live supervision with supervisor at least once per evaluation period and additionally as requested

    3. Comes prepared to discuss client cases with files, completed case notes and prepared with conceptualization, questions, and literature on relevant evidence-based practices

    4. Is prepared to present integrated case conceptualization that is culturally competent

    5. Brings to supervision personal factors, transference, countertransference, and parallel process, and is open to discussion of these

    6. Identifies goals and tasks to achieve in supervision to attain specific competencies

    7. Understands the liability (direct and vicarious) of the supervisor with respect to supervisee practice and behavior

    8. Identifies to clients (and their parents) their status as unlicensed supervisee, the supervisory structure (including supervisor access to all aspects of case documentation and records), and name of the clinical supervisor

    9. Discloses errors, concerns, and clinical issues as they arise

    10. Raises issues or disagreements that may impact the supervision process to move towards resolution

    11. Consults with supervisor or delegated supervisor in all cases of emergency

    12. Implements supervisor directives in subsequent sessions or before as indicated.

 

 

I have read the above agreement and will abide by this agreement.  In addition, I understand and consent to my Site Training Director, Secondary Supervisors, and Training Director to be in contact with my graduate school training department.

 

 

 

Primary Supervisor: _________________________________________            Date: ____________

 

 

Auxiliary Supervisor: _______________________________________            Date: ____________

 

 

CIC Training Director:  ______________________________________            Date: ____________

 

                                                                                                                                   

Intern: ____________________________________________________             Date: ____________

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CONNECTIONS INTERNSHIP CONSORTIUM

Training Director: Kati Hefferon, Psy.D.

900 Technology Way, suite 360

Libertyville, IL 60048

847-680-2715 ext 257