Supervisee Clinical Supervision Notes

Supervisee Name:*
First Last Suffix
Supervisee Email:*
Supervision Date:*
MM slash DD slash YYYY
Start Time:

: Hours

Minutes

AM/PM
End Time:

: Hours

Minutes

AM/PM
Total Time:

: Hours

Minutes

AM/PM
Agenda For Session:
ie: client review, documentation, research, treatment techniques, etc.
Client Identifier:
Client Description:
- New Client
- Update
Demographic:
Presenting Issue:
Treatment Modality Utilized:
- Individual
- Family
- Couple
- Group
Theoretical Approach:
Interventions Utilized:
Treatment Plan:
Suggestions/Follow-Up:
Notes:
Supervisee Signature:*
Sign and INCLUDE CREDENTIALS
Supervisee Signed Date:*
MM slash DD slash YYYY
Clinical Supervisor Signature:
LeAnn Jean, LPC, CPS, MAC
Clinical Supervisor Sign Date:
MM slash DD slash YYYY