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LICENSED PROFESSIONAL COUNSELOR SUPERVISION AGREEMENT - page 1 / 1

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LICENSED PROFESSIONAL COUNSELOR SUPERVISION AGREEMENT

To set goals for supervision based on my personal growth and skill development as a professional counselor;

To periodic evaluation of my goals and a redefining of those goals;

To participate with honest disclosure of cases, particularly difficult and potentially harmful or lethal cases;

To provide weekly summaries for each client on my case load for my supervisor;

And, I will provide a copy of my transcript, proof of liability insurance, record of any license / certification currently held, and a professional disclosure statement;

I agree to maintain my practice within the ethical and legal codes for LPC’s and within the professional standards for LPC’s with careful attention to cultural and ethnicity issues;

I agree to pay $100 for each scheduled hour of supervision.

I agree to pay

  • o

    $50 for each scheduled hour of supervision

    • o

      $75 for each group session of two supervisees

I, ________________________________________________________, as the supervisee, agree to the following requirements for Licensed Professional Counselor (LPC) supervision:

for

________________

Attend supervision on _________________________________ individual / group supervision;

at

As your supervisor, you can expect me to use the roles of teacher, counselor or consultant in my efforts to effectively direct supervision. I want to assure you that I do not do “counseling” with the supervisee. My role of counselor in supervision includes expanding supervisee’s awareness of personal issues which affect their clinical work. If necessary, I will make referrals to “work out” supervisee’s therapeutic blind spots.

My role will be to teach counseling skills and knowledge related to being an effective counselor. I will also

help you expand self-awareness. You will be asked to assess yourself according to the categories of s k i l l s , k n o w l e d g e a n d a w a r e n e s s t o f a c i l i t a t e y o u r g r o w t h . ____________________________________ ________________________________

Supervisee

Date

____________________________________ Supervisor

________________________________ Date

Giordano, M., Altekruse, M., & Kern, C. (2004). Supervisee's bill of rights. In Bernard, J. & Goodyear, R. Fundamentals of Clinical Supervision (3rd Ed.). Pearson Education, Inc.

Giordano, M., Altekruse, M., & Kern, C. (2003). Supervisee's bill of rights. In Haynes. R, Corey, G., & Moulton, P., Clinical Supervision in the Helping Professions. Thompson/Brooks Cole.

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