Nbrrlpc Form PDF Details

Navigating the process of obtaining unrestricted licensure as a North Carolina Licensed Clinical Mental Health Counselor (LCMHC) involves several critical steps, one of which is the completion of the Final Supervision Report by a qualified supervisor. This comprehensive form serves as a pivotal document, encapsulating the essence of the supervised professional practice and clinical supervision experiences of the LCMHC Associate. Designed with precision, the form mandates the use of black ink for clarity and requires detailed information regarding the supervision period, including its duration, modality, and scope of both direct and indirect counseling hours. Supervisors are tasked with providing a thorough summary of the supervision activities, highlighting the strengths and potential areas for improvement of the associate. This report not only includes an assessment of the associate's counseling competencies and professional demeanor compared to peers but also concludes with the supervisor's explicit recommendation concerning the associate's readiness for licensure. The robustness of this form reflects the diligence required in supervising future mental health professionals and ensuring that they are well-equipped with the necessary skills, ethical grounding, and professional integrity to serve their communities effectively. To maintain confidentiality and integrity of the assessment, the completed form must be mailed in a sealed and signed envelope to the North Carolina Board of Licensed Clinical Mental Health Counselors, symbolizing the final step in a journey towards professional development and licensure.

QuestionAnswer
Form NameNbrrlpc Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfinal supervision form, supervision report licensed search, nc supervision report, supervision report form counselors get

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Final Supervision Report

Indicate to which LCMHC Associate this final supervision report applies:

LCMHC Associate Name:

 

LCMHCA (#

)

 

 

 

 

 

 

INSTRUCTIONS: FORMS MUST BE MAILED—NO FAXES OR EMAILS

1.PRINT or TYPE using BLACK Ink to complete this final supervision report.

2.ALL SECTIONS must be completed or the final supervision report will be returned.

3.The Final Supervision Report should be mailed in a sealed envelope, signed across the sealed flap, to the Board Office at:

NCBLCMHC, PO Box 77819, Greensboro, NC 27417

I.GENERAL INFORMATION ‐ Supervisor’s Informa on. Supervisor’s Name (Last, First, Middle):

Mailing Address (Street and/or Box Number, City, State, Zip Code):

Business Phone:

Email Address:

Mobile Phone:

II.FINAL SUPERVISION ‐ To be completed by supervisor. Dates must be entered to be considered complete.

Supervision Period:

Begin Date (mm/dd/yy)

 

End Date (mm/dd/yy)

Modality of Supervision Used (check all that apply):

Live Observa on/Supervision Co‐therapy Audio Recording Video Recording

Supervised Professional Prac ce and Clinical Supervision: (Please enter total hours of supervision)

Supervised Professional Prac ce (as defined in Rule .0208):

Total # Hours Indirect Counseling:

 

 

 

(no more than 40 per week)

Total # Hours Direct Counseling:

 

 

Individual Clinical Supervision (as defined in Rule .0210):

Total # Hours:

 

(no less than 1hr per 40 hrs worked)

Group Clinical Supervision (as defined in Rule .0211):

Total # Hours:

 

(no less than 2hrs per 40 hrs worked)

III.SUPERVISION SUMMARY ‐ To be completed by supervisor. Please provide a summary of the supervision ac vi es completed with this supervisee as well as iden fy strengths and poten al deficits of the supervisee. AƩach addi onal pages as needed.

This version supersedes all previous versions

Final Supervision Report

Revised 2/10/2020

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Name of Applicant: (Required)

IV. PROFESSIONAL ASSESSMENT ‐ To be completed by supervisor.

Please rate the applicant compared to other counselors you know on the characteris cs listed below. Place a mark in the appropriate column for each characteris c using the following ra ng scale:

1 = Outstanding

2 = Above Average 3 = Average

4 = Below Average

5 = Not Qualified

6 = Cannot Evaluate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

3

4

5

6

 

Comments

 

 

 

 

 

 

 

 

 

 

Individual counseling skills

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnos c skills

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment planning implementa

on

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appropriate referral making

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appropriate record keeping

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Group counseling skills

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Personal integrity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Consul ng skills

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insight into client's problems

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ability to relate to co‐workers

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ability to be objec

ve on the job

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Knowledge of assessment instruments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethical conduct

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Concern for the welfare of clients

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sense of responsibility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Recogni on of own limits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ability to keep material confiden

al

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V. REFERENCE ‐ To be completed by supervisor.

I recommend do not recommend this applicant for unrestricted licensure as a NC Licensed Clinical Mental Health Counselor.

INITIAL (Required)

If you do not recommend this applica on for unrestricted licensure please indicate below your reasons why:

VI. VERIFICATION ‐ To be completed by supervisor.

I verify that the above informa on is accurate. The focus of the documented supervision sessions was based on raw data from clini‐ cal work which was made available to the supervisor through such means as live observa on, co‐therapy, audio and video record‐ ings, and live supervision. The clinical supervision included a minimum of one hour of individual or 2 hours of group clinical supervi‐ sion per 40 hours of counseling prac ce.

Supervisor’s Signature:

 

Date:

Aer comple ng this form, please enclose it in a sealed envelope, sign across the sealed flap, and return to the NC Board of Licensed Clinical Mental Health Counselors.

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