Supervision Plan for Applicants and Provisional Members

Consent for Release of Information to Supervisor(s)
This form will be used to release information to your supervisor(s) regarding your provisional membership. This may include but is not limited to complaint issues, previous provisional licensure supervisor evaluations, etc.
Name*

First NameLast Name
Email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby give consent for the Saskatchewan College of Psychologists to release information to my proposed/approved supervisor(s) during my provisional practice period, regarding any information about my provisional membership and/or my competency to practice psychology.
Signature*

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Date*

MonthDayYear
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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Consent for Release of Information to Supervisor(s)