PSYCHOTHERAPY SUPERVISION CONTRACT
PSYCHOTHERAPY SUPERVISION CONTRACTGENERAL INFORMATIONName, degree, qualifications, credentials of psychotherapy supervisor: _____________________________________________________________________________Name of supervisee: _______________________________________Name of graduate school supervisee has attended/is attending: _________________________________________________________________________________________________________Supervisee’s professional degree/status of current professional training: ____________________________________________________________________________________________________________________________________________________________Name of regulatory board, if supervisee is meeting licensure requirements:Name of place of employment/employer: __________________________________________________________________Purpose of psychotherapy supervision (e.g., level of licensure pursuing, etc.): _____________________________________________________________________________Type of supervision requested (individual or group): ___________________________________Number of supervision hours required: ____________________Frequency of supervision sessions necessary to meet requirements: _______________________Description of supervisee’s client population: _________________________________________Treatment methods and modalities supervisee will use with clients:________________________________________________________________________Types of cases required to meet supervision requirements: ____________________________________________________________________________________________________________________________________________________________Date formal supervision evaluation(s) must be conducted: _______________________________Criteria that will be used in formal evaluations: _____________________________________________________________________________________________________________________Names and addresses of individuals to whom supervisory evaluations will be sent: ____________________________________________________________________________________________________________________________________________________________Policy/ method supervisee will use to contact the clinical supervisor: ______________________________________________________________________________Procedures supervisee will use to respond to client emergencies: ______________________________________________________________________________PSYCHOTHERAPY LEARNING NEEDS ASSESSMENT:Transcripts of supervisee’s academic courses (attached).Current job description (attached).Resume or list of prior professional experiences, responsibilities, and duties (attached).Prior professional experience that is relevant to the supervisee’s current patient population: ____________________________________________________________________________________________________________________________________________________________Knowledge and skills supervisee acquired from previous professional training and experience such as: diagnostic assessment and treatment; ethical standards of practice; state and federal laws and rules; record keeping; cultural competence, e.g., knowledge and experience with cultural norms of behavior for clients served by the supervisee (e.g., ethnicity, race, age, class, gender, sexual orientation, religion, immigration status, literacy, and mental or physical disability); commitment to maintaining cultural competence as an ongoing process; methods for establishing treatment relationship with clients and patients; methods for including family members in clients’ treatment when appropriate; communication with other professionals in developing diagnosis and treatment plans and assuring continuity of care:____________________________________________________________________________________________________________________________________________________________Professional strengths supervisee has that supervisee, teachers and former supervisors have identified:Professional weaknesses or concerns about supervisee’s practice that the supervisee, teachers and former supervisors have identified:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Supervisee’s greatest sources of professional concerns and anxiety:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Supervisee’s specific learning needs, including skills supervisee needs to develop:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________How supervisee learns best:______________________________________________________________________________Learning barriers and accommodations, if any, needed: ______________________________SUPERVISEE’S RIGHTSThe right to have weekly (or other predictable frequency) supervisory sessions that will focus on my learning needs and my clients’ treatment needs;The right to understand and to participate in the development of my learning objectives, activities to meet learning objectives, and standards for mastery of learning objectives;The right to know my supervisor’s professional qualifications (training, licensure, competencies, experience, education, treatment approach, biases, etc.);The right to have regularly scheduled performance evaluations and to have my performance evaluations sent in a timely manner to the appropriate institution (for example, graduate school, regulatory board, employer);The right not to be discriminated against in the provision of supervisory services on the basis of my race, gender, ethnic origin, disability, creed, or sexual orientation;The right not to be harassed or exploited to meet my supervisor’s personal needs;SUPERVISEE’S RESPONSIBILITIESTo collaborate with my psychotherapy supervisor in developing a learning needs assessment and supervision plan;To bring my psychotherapy cases, including records, to my clinical supervisor for honest and direct discussion and review;To provide my psychotherapy supervisor with access at any time to my patients’ records for review;To thoroughly present each of my clients’ cases verbally and in writing, including all factors relevant to diagnosis and treatment, including but not limited to: presenting problems; history of problems; significant childhood, family relationship, work, and other life history; medical treatment; medications; past treatment; mental status observations; diagnoses and treatment plans; my process of providing informed consent; my clinical interventions, including attention to high risk or safety concerns; preventive action taken; referrals; means of evaluating my clients’ progress, record keeping, and other professional issues, including transference and counter transference. To inform my patients of exceptions to confidentiality, including that my psychotherapy supervisor will be discussing my sessions, reviewing case notes and electronic recordings of patient sessions;To obtain my patients’ informed consent in writing for any electronic recording of sessions for purpose of supervision;To read, understand, and adhere to my office’s and psychotherapy supervisor’s security and privacy policies and procedures;To follow state and federal laws and rules and professional ethical standards and to discuss ethical and legal questions or other problems as they arise in each of my cases.PSYCHOTHERAPY SUPERVISOR’S RESPONSIBILITIESTo provide supervision appropriate to my supervisee’s professional needs and that meets the requirements of professional ethics and state and federal laws and rules; To schedule regular supervisory meetings with my supervisee and be available for emergencies (or specify another supervisor available for emergencies);To develop a learning needs assessment with my supervisee and establish clear learning objectives and criteria for mastery of learning objectives;To teach practical clinical skills, including the characteristics and contents of good clinical records, and help my supervisee integrate theoretical knowledge with clinical skills in order to develop professional competence;To help my supervisee appropriately manage transference, counter transference, and professional boundary issues;To help my supervisee understand cultural norms;To help my supervisee understand ethical standards;To help my supervisee identify when a patient may have special problems that require another professional’s consultation;To regularly assess and provide feedback on my supervisee’s progress, including identification of strengths, weaknesses, and errors, and to work with my supervisee to develop plans for improvement;To conduct formal performance evaluations at 6-month intervals (or other predetermined interval);To honestly communicate my supervisee’s performance evaluation results, including professional strengths as well as any unresolved practice errors or clinical and ethical concerns, to those persons who require supervisee’s performance evaluation; To meet and adhere to supervisor requirements of the (licensure board that regulates my practice).PSYCHOTHERAPY SUPERVISOR’S RIGHTSThe right to information needed to provide appropriate supervision;The right to be compensated promptly for supervision services as agreed upon and when payment arrangement is applicable;The right to provide supervision in an atmosphere free of verbal, physical, or sexual harassment;The right to terminate supervision when in my professional opinion it is not effective.The right to determine terms and conditions of termination of supervision contract, which are that this supervision contract may be terminated with two weeks written notice by either party.By signing, we agree that the above information is accurate and that we agree to follow the terms, rights and responsibilities as outlined in the psychotherapy supervision contract.Supervisee Signature: ______________________________Date: ______________________________Supervisor Signature: ______________________________Date: ______________________________ Other Signature(s): ______________________________Role: ______________________________Date: ______________________________Addendum for External Psychotherapy Supervision (Occurring outside of training program or employment)When the supervisor who is providing clinical supervision is not employed by the supervisee’s place of employment or training program, there are additional considerations that the external clinical supervisor needs to discuss with the supervisee and the professional staff within the supervisee’s training program or place of employment. These may include the need to define the external psychotherapy supervisor’s competence to supervise the cases from the training program, agency or clinic etc.; the need to define respective supervisory responsibility and limits of responsibility for the supervisee’s practice; methods for handling discrepant direction from training supervisor or employer versus the external psychotherapy supervisor; confidentiality and privacy; mandated reporting; performance issues.The following can be discussed and agreement reached before beginning the supervisory relationship:Describe treatment modalities utilized/required by the training program, clinic, agency, etc.:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Describe treatment modality competencies held by the external psychotherapy supervisor:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Reason for referral to external psychotherapy supervisor:Describe who has responsibility for the supervisee’s performance:______________________________________________________________________________Describe what information from supervisory communications will be shared with the training program, agency, or clinic:______________________________________________________________________________Describe how conflict between agency and supervisor expectations will be negotiated:______________________________________________________________________________Describe how patients’ therapy records will be handled to protect patients’ privacy and confidentiality: ______________________________________________________________________________Describe exceptions to supervisee’s privacy and confidentiality: ______________________________________________________________________________Identify the supervisor responsible for the supervisee at the place of training or employment and their contact information:Name: ______________________________________Address: ____________________________________Phone: ______________________________________Email: ______________________________________By signing this addendum, I give permission for my supervisor and employer or training program to communicate on any issues that may create ethical or legal issues or practice problems.Supervisee’s Signature: ____________________________________Date: ______________Supervisor’s Signature: ___________________________________Date: _______________Name/title of staff member administratively responsible for supervisee at place of employment Signature: ______________________________________________________ Date:_________ ................
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