Supervisee Clinical Supervision Notes

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

: HH

MM
End Time:

: HH

MM
Total Time:

: HH

MM
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:*
Date Format: MM slash DD slash YYYY
Clinical Supervisor Signature:
LeAnn Jean, LPC, CPS, MAC
Clinical Supervisor Sign Date:
Date Format: MM slash DD slash YYYY

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