Supervisee Clinical Supervision Notes Supervisee Name:* First Last Suffix Supervisee Email:* Supervision Date:* Date Format: MM slash DD slash YYYY Start Time: : HH MM AM PM End Time: : HH MM AM PM Total Time: : HH MM 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 CREDENTIALSSupervisee Signed Date:* Date Format: MM slash DD slash YYYY Clinical Supervisor Signature:LeAnn Jean, LPC, CPS, MACClinical Supervisor Sign Date: Date Format: MM slash DD slash YYYY Visits: 77
