Supervision Agreement for Provisional Practice

Supervision Agreement for Provisional Practice
For Office Use Only: Job # and Workplace
Please note this form must be completed for each workplace*

Please check
Please check the appropriate box:*

Agreement of applicant for a provisional membershipAmended agreement for a current provisional member
*Please refer to the Handbook for Provisional Applicants and Members (under revision).

This agreement defines a relationship of supervision between the parties named below.

The applicant/provisional member must complete the required fields, then sign, date, and submit the form. Others required to sign and date will be forwarded a link with instructions.

Supervisee:
Name of Supervisee*

First NameLast Name
Supervisee Email*
Degree & Major/Specialization (as indicated on your transcript)*
Supervisee Workplace*
Primary Supervisor:
Name of Primary Supervisor*

First NameLast Name
Primary Supervisor Email*
Degree*
Supervisor Workplace*

Secondary Supervisor (1)
Name of Secondary Supervisor (1)

First NameLast Name
Secondary Supervisor (1) Email
Degree
Secondary Supervisor (1) Workplace
Please check if supervision is delegated by the primary supervisor for a competency of which the primary supervisor has not declared.
Specific delegated competency, including population(s) served
Secondary Supervisor (2)
Name of Secondary Supervisor (2)
Secondary Supervisor (2) Email
Degree
Secondary Supervisor (2) Workplace

The Secondary Supervisor (1) Agrees to (check each acknowledging your full agreement):

Have a full practicing membership of the College for one year and be in good standing.Only provide supervision to the supervisee of which the primary supervisor has specifically delegated to the secondary supervisor, and provide such supervision face-to-face (either in-person or virtually).Complete an independent evaluation of any delegated competency at the 750 hour and 1500 hour points.Follow the provincial legislation that governs the Saskatchewan College of Psychologists (including The Psychologists Act, 1997, the regulatory bylaws, and all other relevant bylaws); the Canadian Code of Ethics for Psychologists - most recent edition; SCP Professional Practice Guidelines; relevant provincial and federal legislation; and College policy.Count group supervision at half the time of individual supervision (e.g., one hour of group supervision is logged at .5 hours). It must not exceed 1/3 of the logged hours (i.e., 19 hours), and must be conducted only be approved supervisors.
Secondary Supervisor (1) Signature

Clear
Date

MonthDayYear
Date
The Secondary Supervisor (2) Agrees to:

Only provide supervision to the supervisee of which the primary supervisor has specifically delegated to the secondary supervisor. Provide such supervision face-to-face (either in-person or virtually).Follow the provincial legislation that governs the Saskatchewan College of Psychologists (including The Psychologists Act, 1997, the regulatory bylaws, and all other relevant bylaws); the Canadian Code of Ethics - most recent edition; SCP Professional Practice Guidelines; relevant provincial and federal legislation; and College policy.Count group supervision at half the time of individual supervision (e.g., one hour of group supervision is logged at .5 hours). It must not exceed 1/3 of the logged hours (i.e., 19 hours), and must be conducted only by approved supervisors.
Secondary Supervisor (2) Signature

Clear
Date

MonthDayYear
Back-Up/Emergency Supervision

In the event that the primary and secondary supervisors are unavailable, there must be a back-up/emergency supervisor (who does not need to be a registered psychologist), and (ideally) who is located at the supervisee's place of employment.

Please note: Back-up/emergency supervision cannot be counted/logged towards the direct supervision requirement. Moreover, the back-up/emergency supervisor cannot sign off on any psychological work/documents/reports completed by the supervisee.
Please List all Back-Up/Emergency Contacts
Please include job title and location.
Saskatchewan College of Psychologists

1026 Winnipeg Street, Regina, SK S4R 8P8
Telephone: 306-352-1699/Fax: 306-352-1697
Email: skcp@sasktel.net
Website: www.skcp.ca
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