Clinical Supervision Form (LeAnn Jean LPC, CPCS, MAC) NEW

This form is to be used for Clinical Supervision under the direction of LeAnn Jean, LPC,CPCS, MAC.

Clinical Supervision Date:
Date that the clinical supervision took place.
Time In:
:
Include the start time of your clinical supervision meeting.
Time Out:
:
Include the end time of the clinical supervision meeting.
Total Time
:
Based on your time-in and time-out time Include the total time you were in the clinical supervision meeting.
Modality:
Location:

Clinical Supervisor Signature, LeAnn Jean LPC, CPCS, MAC

Sign (include credentials) and date below.
Clear Signature
Date Signed - Clinical Supervisor

Counselor's Signature:

Type and sign name (include credentials), add email and date below.
Printed Name and Credentials of Counselor:
Clear Signature
Date Signed - Counselor: