Supervision Agreement with Intern

Document Sample
Supervision Agreement with Intern Powered By Docstoc
					                             Adoption Related Services of Pinellas
                        8800 49th Street N. Suite 212  Pinellas Park, FL 33782
                              (727) 423-7811 

                                        SUPERVISION AGREEMENT

This is an agreement between , Registered Mental Health Counselor Intern (License Number IMH             ) and
Linda Eaton, LMHC (License Number MH5534) for supervision as outlined in Florida Statutes chapter 491 and
Florida Administrative Code Rule Chapter 64B4 of the Board of Clinical Social Work, Marriage and Family
Therapy and Mental Health Counseling. In this agreement, the party who is contracting to receive the services
(Registered Mental Health Counselor Intern) shall be referred to as “Supervisee” and the party who will be
providing the services shall be referred to as “Qualified Supervisor”. Both parties agree that requirements have
been met for their respective roles of Registered Mental Health Counselor Intern and Qualified Supervisor
according to Florida Statute chapter 491.

   1. Supervision will be provided as follows (check all that apply):
                  Individual supervision will be conducted every 2 weeks for 1 hour and may include a 2nd
                  Group supervision will be conducted every      weeks for    hour and may include up to 6
   2. It is understood that the frequency of supervision may need to be adjusted to satisfy the ratio of face-to-
      face client hours with supervision hours (1 hour of supervision for every 15 hours of client contact).
   3. This agreement will be valid for a period of six months. At the end of that period, the agreement may
      be renegotiated for an additional six months.
   1. Either party may terminate this agreement with a 30 day written notice.
   2. This agreement can be terminated immediately under any of the following conditions.
           a. Supervisee is found guilty or pleads no contest to any provision of Florida law or rule that
              regulates the practice of Mental Health Counseling that could result in revocation of a license.
           b. Supervisee does not complete required remediation in the time allotted.
           c. Supervisor is disciplined by the Board of Clinical Social Work, Marriage and Family Therapy and
              Mental Health Counseling.
Responsibilities of Supervisee
   1. Supervisee is responsible for verifying license application and supporting documents are in order and
      filed as required.
   2. Supervisee shall actively protect each client’s rights and safeguard their welfare.
   3. Supervisee will obtain an informed consent from all clients that explains discussion of their case in
      supervision. The original will be kept in the client file and a copy provided to the Qualified Supervisor.
   4. Supervisee agrees to keep accurate records of all clients while under supervision.
   5. Supervisee will be prepared to review any case as requested by the Qualified Supervisor. Methods of
      review include discussing cases, reviewing written documentation, or reviewing other forms of raw data
      such as audio or video tapes.
   6. Supervisee will actively participate in the evaluation process, including self-evaluation.
   7. Supervisee will actively participate in completing a supervision plan to outline goals and objectives for

                                    Keeping Adoptive Families Together
Supervision Agreement
   8. Supervisee is responsible for remediating any and all deficiencies in training, if such should occur
      during supervision. Supervisee is responsible for informing Qualified Supervisor of any perceived
      deficits in training, specifically as it pertains to client safety and risk management.
   9. Supervisee will keep a log of clinical hours worked and supervision received and is responsible to have
      the Qualified Supervisor verify the accuracy of this log.
   10. Supervisee agrees to keep supervision appointments as scheduled and notify Qualified Supervisor if
       unable to keep any appointment. If Supervisee arrives late for an appointment, it is understood that
       time may be lost from the supervision time.
Responsibilities of Qualified Supervisor
   1. Qualified Supervisor, in collaboration with Supervisee, will develop a supervision plan to outline goals
      and objectives for supervision.
   2. Qualified Supervisor will provide an assessment of the Supervisee’s strengths and needs, monitor
      progress of clinical work, and provide consultation on client cases during supervision.
   3. Qualified Supervisor will document the supervision through progress notes.
   4. Qualified Supervisor will provide written evaluation of Supervisee’s progress toward established
      supervision goals as outlined in the supervision plan.
   5. Upon conclusion or early termination of this agreement, the Qualified Supervisor shall complete and
      sign a Supervised Experience Attestation Form to document the hours of supervision provided.
   1. The fee schedule for supervision is as follows:
                $50/hour for 1-6 clients of supervisee
                $75/hour for 7-12 clients of supervisee
                $100/hour for more than 12 clients of supervisee

   2. Payment shall be made no less frequently than once per month.

By signing below, I am agreeing to the terms and conditions of the supervision agreement as outlined above.

, Registered Mental Health Counselor Intern         Date

Linda Eaton, Qualified Supervisor                                  Date

                                                     2 of 2

Shared By:
Description: Supervision Agreement with Intern document sample