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Informed Consent Agreement for Post Degree Clinical Supervision.
Purpose
Informed consent is given as a way to set a container for the process of supervision and to
create an understanding between supervisor and supervisee about what supervision entails. This
form is designed to describe supervision, inform you about me and my theoretical orientation,
provide structure for your experience, clarify expectations, and ensure a common understanding
of our work together.
Professional Disclosure
I, Janys M. Murphy, PhD, LMHC, CMHS attest to the fact that I am an “approved
supervisor” as defined by WAC 246-809-234 (License # LH000010196). I have held license
without restrictions since obtaining licensure in March of 2006. I have over 12 years in the mental
health field, and 5 years in substance abuse treatment.
I earned a PhD in Counseling at Oregon State University in March of 2013. I earned a
Master of Arts in Counseling Psychology from Saint Martins University in August of 2003. I am
self employed as a Licensed Mental Health Counselor. I have extensive experience with chemical
dependency counseling. I work with children, adolescents, and adults, couples, and families.
Prior to this I was the Lead Therapist for the Family and Adolescent Co-occurring Treatment
Program at Behavioral Health Resources in Olympia Washington. There I worked with
adolescents and families with co-occurring mental health and substance abuse issues. I was
credentialed as a Child Mental Health Specialist in 2007. I became certified as a Chemical
Dependency Professional 2006. I have extensive experience in clinical assessments and
diagnostics in both mental health and chemical dependency placement criteria.
I have worked in school based treatment from elementary to high school. I have
developed two programs one for brief group therapy, and a designed a second program with
psycho-education, process, and experiential group treatment. I was grandfathered in as a Mental
Health Professional and received credentialing while working at Seattle Mental Health in Seattle
WA in 2005. I have a specialized interest in trauma, body image, eating disorders, addiction,
women’s issues, and adolescent normative development.
In addition to obtaining licensure as a mental health counselor prior to September of
2006, I completed 15 clock hours of clinical supervision training in May of 2009. I am required to
furnish signed proof that I am deemed a clinical supervisor in the state of Washington and will
need a copy with your signature as well at the first meeting of supervision.
As part of my coursework for Oregon State University I completed coursework in clinical
supervision and advanced supervision. This course satisfies the minimum requirement for Oregon
supervisors, which exceeds the standards in Washington State as of 2010. I received supervision
of supervision from a PhD level supervisor as part of my doctoral training.
Counseling modalities in my own practice include Psychodynamic, Mindfulness,
Interpersonal Neurobiology, Yoga Therapy, Brief Strategic Family Therapy, Multi-Dimensional
Family Therapy, Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, and
Motivational Interviewing.
Supervision Process
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I aim for your supervision to be professionally rewarding and hope that you look forward
to and feel benefitted by it. In addition to obtaining licensure, supervision has the purpose of
fostering professional growth as well as enhancing the skill of the supervisee while keeping the
client from harm. I have a responsibility to review your work fairly and accurately, and in
accordance to professional, organizational, and state policies that review professional licensure.
My expectation for you is to be an active participant, arrive on time, be prepared for each
session, and complete work in a timely manner. I may request that you do additional readings,
attend trainings, participate in additional supervision hours, or bring in audio or videotapes of
your work for us to discuss together. In addition, personal therapy for mental health counselors is
a value of mine as I think it deeply enriches the skill level of the therapist. Please understand that
if I do recommend personal therapy for you, it is in the context of increasing your professionalism
and skill level.
I invite you to explore alternatives, address ethical and multicultural concerns, and
receive feedback and suggestions on therapeutic interventions as we work together. I welcome
any questions and comments that you may have about supervision and look forward to working
with you.
Methods
The methods I employ for clinical supervision include Bernard’s Discrimination Model,
Stoltenberg and McNeil’s Integrated Developmental Model, both Visual and Active Supervision
techniques, as well as Multicultural and advocacy model of Dr. Nieto.
Practical Issues
To adequately work on your professional development, we need to meet on a consistent
basis. Supervision is always conducted at my office in Olympia, WA and will be scheduled in
advance. Payment is 95.00 for a 50 minute session. If a circumstance arises that makes it
impossible for you to attend a scheduled session please let me know as soon as possible. If you
cancel supervision with less than 24 hours notice you will still be responsible for the fee. If I
cancel with less than 24 hours notice, then your next session appointment will be at no charge.
If an emergency arises, or if you need to speak to me in between sessions, please contact
me at (360) 754-1747. Please err on the side of caution in regards to client concerns during our
supervisor relationship. I would prefer to know too much than not enough. When you call me I
will return your call in a timely manner. If I am out of town I will give you the name and
telephone number of another approved supervisor who is available to you in my absence.
WAC 246-809-334 states that in providing clinical supervision for a candidate for
licensure, I must have a thorough knowledge of your practice activities, including but not limited
to: record keeping, financial management of your practice, ethics in clinical practice, and the
supervisee’s backup for coverage in the event of absence or inability to perform his or her
responsibilities to the client.
Therefore, as supervisee you agree to:
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1. Set up your record keeping procedures as requested by me during the time that I am your
supervisor.
2. Make client records available to me upon request. Clients must be made aware that you
are in a supervisory relationship with me as required by the State of Washington in order
to obtain licensing.
3. Show me your Client Disclosure Statement for review. Your status as a supervisee must
be clearly stated for the client to read and understand.
4. Acquire the required licenses and permits from the Department of Health, federal, state,
and local governments and other jurisdictions as required for professional purpose.
5. Provide me with proof of current liability insurance in the amount of 1,000,000/3,000,000
and Washington State counselor registration. This must be your own insurance, not the
agency that you work for.
6. Obtain the Code of Ethics for your discipline and become familiar with it. Discuss you
backup plan for coverage when you are away.
7. Provide any and all files for review at any time because as your supervisor I am legally
responsible for your work.
8. I will not be held responsible for information withheld or misinformation received
regarding specific clients. Further, I will not be held responsible for direct of indirect
unwillingness to follow suggestions or directives regarding specific clients.
As the supervisor I agree to:
1. Keep you informed of changes to the Washington Administrative Code (WAC) that
effect the profession of mental health counseling.
2. Give you feedback on a regular basis.
3. Examine client presenting problems and treatment plans and sign off on all client
documentation.
4. Maintain ongoing supervision notes.
5. Ensure that ethical guidelines are upheld and related to the clinical work you are
providing to your clients and the clinical supervision that I am providing you.
6. Present and model appropriate directives while supporting your development as
acounselor.
7. Monitor your skills and challenge you to justify your approach, techniques, and
interventions.
8. Intervene when a client’s welfare is at risk.
Legal or Ethical Issues
The supervisor/supervisee relationship is not intended to provide you with personal
counseling or therapy. Information disclosed within sessions is kept strictly confidential except I
am limited legally if counselor treatment of a client violates the legal and ethical standards set
forth by professional counseling associations and government agencies. Additionally, I have an
ethical responsibility to acquire additional supervision myself if warranted to assure that your
practice is upheld at the minimum standards.
It is essential that we share positive rapport in order to ensure successful supervision for
you. If relationship concerns between us arise, then it is up to both of us to discuss concerns and
work towards resolution. In the event that resolution is not possible, and it is not in our best
interest of one or both of us to continue the supervisor/supervisee relationship, then this
agreement may be dissolved in writing. All hours accumulated to that point will be signed off
(except those in dispute) and the supervisory relationship will be dissolved.
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Statement of Agreement
By signing below, you affirm that you have read and understand the informed consent
agreement for post degree supervision with approved supervisor Janys M. Murphy. Additionally
your signature attests that you agree to participate in supervision according to these guidelines.
Printed Name of Supervisee________________________
___________________________________
Supervisee Signature
__________________
Date
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Supervisor Signature
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Date