External Supervision Contract

External Supervision Contract
Supervisee Name *

First Name Last Name
Supervisee Phone Number *
Supervisee Address *

Street Address

City State / Province

Postal / Zip Code
Supervisee Email *
example@example.com
Supervision Start Date *

Month Day Year
Date
Agency
License can be uploaded here

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Cancel of
Please upload Proof of Liability Insurance Certificate here

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Cancel of
Supervision Fee Based on a 50-Minute Session
$$
Supervision will include the following:
- Case consultation, with decision making authority on cases being held by the agency the supervisee comes from, including emergencies
- Discussion of Ethical concerns
- Therapist work
- Mutual evaluation and ongoing feedback
- Education as agreed upon
Goals will be developed in a mutual process and may change over time
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Cancellations require 24-hour notice from the Supervisee, with a fee for late cancellations or no shows, at the discretion of the Supervisor. If the Supervisor misses a session, the following session will be provided without charge.

We acknowledge by our individual signatures below, that each of us has read this Contract, that we understand it and have had an opportunity to discuss its content and that we enter Supervision in agreement with this Contract
Supervisee Signature *

Clear
Supervisor Name

First Name Last Name
Supervisor Signature & Date
Should be Empty: