Supervisee Clinical Supervision Notes Supervisee Name:* First Last Suffix Supervisee Email:* Supervision Date:* MM slash DD slash YYYY Start Time: : Hours Minutes AM PM AM/PM End Time: : Hours Minutes AM PM AM/PM Total Time: : Hours Minutes AM PM 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:* Reset signature Signature locked. Reset to sign again Sign and INCLUDE CREDENTIALSSupervisee Signed Date:* MM slash DD slash YYYY Clinical Supervisor Signature: Reset signature Signature locked. Reset to sign again LeAnn Jean, LPC, CPS, MACClinical Supervisor Sign Date: MM slash DD slash YYYY Δ
