Clinical Consultation & Clinical Supervision Questionnaire
"Stand OUT from the REST"
Agency/ Individual Name
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First Name
Last Name
Date Business Started
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Location ( Service)
Service(s)
Services Offered/Nature of work:
How many social workers do your agency employ, if appliacable?
Do You or your agency use evidence based tools?
Service Delivery Methods
Virtual
Both Virtual & Face to Face)
Face to Face
In home
Is this agency accredited, if so, for how many years ( if applicable) ?
Name of accrediting body if applicable
Do the agency have a EHR system, if so, what is the name?
Do your agency have a need for online forms?
Yes
No
How do you currently advertise for your services?
Do you have a need for a marketing plan?
Is this a trauma informed workplace?
How often are you required to make clinical decisions based on your role?
Never
Rarely
Sometimes
Often
Very often
How many Employees, contractors and clients do you actively serve?
Do you have plans for expansion?
Yes
No
If so, please specify the service(s) that will expand?
How many years of mental health experience do your leadership team have?
Funding of programs
Are you contracted with any MCO, if yes, Please specify which ones.
What specific service (s) are you looking to outsource?
Do you have specific days & times for conference calls?
Do you accept insurance? if so, who are they?
What insurance source would be considered, your BIGGEST funding source?
Do you provide pro-bono services?
Are you an IPRS provider??
Yes
No
Leadership /Learning Style
On a scale of 1-10 what would you rate your ability to supervise/lead others?
How do you typically handle conflict?
Email the individual
Avoid it all together
Hold Private Meeting
Refer to Supervision Plan
How would you describe the best way for you to learn?
Are you familiar with vicarious supervision?
Yes
No
If so, please define and/or provide an example?
What is your long range plan for clinical supervision or clinical consulting (ie. be very specific)?
Are you receptive to corrective feedback?
Yes
No
Describe your short range & long range plans (ie. 5yrs)
Submit
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