Form Supervisory Plan PDF Details

The Supervisory Plan form plays a critical role in the journey of associate clinical social workers and professional clinical counselor interns in the State of California, serving as a foundational document that outlines the supervisory relationship between these aspiring professionals and their licensed mental health supervisors. Governed by specific sections of the California Code of Regulations and the Business and Professions Code, this form mandates thorough documentation of the supervisor-supervisee relationship, including detailed personal and professional information about both parties, the employment setting, and the primary objectives of the supervision. This process not only ensures that all parties understand their roles and responsibilities but also serves as an official record that must be submitted to the Board of Behavioral Sciences upon the registrant's application for examination eligibility. Completing and signing this form is a declarative act, with both supervisor and supervisee certifying their understanding and acceptance of their duties in the supervisory process, highlighting the importance of this documentation in maintaining the integrity and efficacy of clinical supervision in the mental health profession in California.

QuestionAnswer
Form NameForm Supervisory Plan
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameslcsw supervisory plan, bbs lpcc supervisory plan, plan supervision, bbs supervisory

Form Preview Example

STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY

Governor Edmund G. Brown Jr.

BOARD OF BEHAVIORAL SCIENCES

 

1625 North Market Blvd., Suite S200, Sacramento, CA 95834

Telephone: (916) 574-7830 TTY: (800) 326-2297

www.bbs.ca.gov

SUPERVISORY PLAN

Title 16, California Code of Regulations (CCR) Sections 1870.1 and 1822 require all associate clinical social workers and professional clinical counselor interns and licensed mental health professionals acceptable to the Board as defined in Business and Professions Code Section 4996.23(a), 4999.12(h) ,and CCR Section 1874, who assume responsibility for providing supervision to those working toward a license as a Clinical Social Worker or Professional Clinical Counselor to complete and sign the following supervisory plan. The original signed plan shall be submitted by the registrant to the board upon application for examination eligibility.

REGISTRANT: (Please type or print clearly in ink.)

Legal name:

Last

First

Middle

Registration Number

Address:

Number and Street

City

Business Telephone

()

State

Zip Code

 

 

Residence Telephone

()

LICENSED SUPERVISOR: (Please type or print clearly in ink.)

Name:

Last

First

Middle

License No:

Expiration Date:

Employer Name:

 

Telephone Number:

 

 

(

)

 

 

 

 

Address:

Number and Street

 

City

State

Zip Code

Employment Setting:

 

 

a.

Private Practice

d.

Licensed Health Facility

a.

Governmental Entity

e.

Social Rehabilitation Facility/Community Treatment Facility

b.

Nonprofit and Charitable Corporation

f.

Pediatric Day Health and Respite Care Facility

c.

School, College, or University

g.

Licensed Alcoholism or Drug Abuse Recovery or Treatment Facility

 

 

h.

Community Mental Health Facility

Briefly describe the goals and objectives:

I certify that I understand the responsibilities regarding clinical supervision, including the supervisor’s responsibility to perform ongoing assessments of the supervisee, and I declare under penalty of perjury under the laws of the State of California that the information submitted on this form is true and correct.

Supervisor’s Signature

Date signed

 

 

Registrant’s Signature

Date signed

The original of this form must be submitted to the board upon application for examination eligibility.

37A-521 (Rev.3/10)

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Completing section 1 in plan supervision

2. The subsequent step is usually to fill in all of the following fields: Number and Street, Telephone Number, State, Zip Code, d Licensed Health Facility e, Address, City, Employment Setting, a Private Practice a Governmental, Briefly describe the goals and, I certify that I understand the, Date signed, Registrants Signature, and Date signed.

plan supervision writing process outlined (portion 2)

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