Nbrrlpc Form PDF Details

Are you a business owner looking to streamline your paperwork and compliance with the Nbrrlpc form? The Nbrrlpc form is an important element of regulatory compliance in certain jurisdictions, and having it filled out correctly can help to ensure that all of your operations run smoothly. In this blog post, we'll discuss what the Nbrrlpc form entails, how to go about filling it out properly, and where you can find additional information that may be useful when completing this important document. Read on for more details!

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

Form Preview Example

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

Page 1 of 2

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.

Page 2 of 2

How to Edit Nbrrlpc Form Online for Free

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Step 1: First of all, open the pdf tool by clicking the "Get Form Button" in the top section of this site.

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When it comes to blank fields of this precise PDF, here's what you need to do:

1. To begin with, when filling out the final supervision, start with the part with the following fields:

Completing segment 1 in final supervision form

2. Just after the last selection of blank fields is done, go on to enter the relevant details in these: Comments, Individual counseling skills, and Diagnoscidc skills Treatment.

final supervision form completion process clarified (portion 2)

3. The next step will be simple - fill in every one of the form fields in Diagnoscidc skills Treatment, INITIAL Required, VI VERIFICATION To be completed, Supervisors Signature, Date, Acider complecidng this form, the NC Board of Licensed Clinical, and Page of to conclude the current step.

Part # 3 of completing final supervision form

As to Page of and the NC Board of Licensed Clinical, be sure you do everything properly here. The two of these could be the most important ones in this PDF.

Step 3: Check all the details you have entered into the blank fields and click the "Done" button. After setting up afree trial account at FormsPal, you'll be able to download final supervision or send it via email immediately. The document will also be readily available in your personal account page with all of your changes. FormsPal ensures your information privacy by using a secure system that in no way saves or shares any type of personal data involved in the process. Be confident knowing your files are kept safe every time you use our services!

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