PSYCHOTHERAPY
SUPERVISION CONTRACT
GENERAL INFORMATION
Name, degree, qualifications, credentials of psychotherapy supervisor:
_____________________________________________________________________________
Name of supervisee: _______________________________________
Name of graduate school supervisee has attended/is attending: ___________________________
______________________________________________________________________________
Supervisee’s professional degree/status of current professional training:
______________________________________________________________________________
______________________________________________________________________________
Name of regulatory board, if supervisee is meeting licensure requirements:
Name of place of employment/employer:
__________________________________________________________________
Purpose of psychotherapy supervision (e.g., level of licensure pursuing, etc.):
_____________________________________________________________________________
Type of supervision requested (individual or group): ___________________________________
Number of supervision hours required: ____________________
Frequency of supervision sessions necessary to meet requirements: _______________________
Description of supervisee’s client population: _________________________________________
Treatment methods and modalities supervisee will use with
clients:________________________________________________________________________
Types of cases required to meet supervision requirements:
______________________________________________________________________________
______________________________________________________________________________
Date formal supervision evaluation(s) must be conducted: _______________________________
Criteria that will be used in formal evaluations: _______________________________________
______________________________________________________________________________
Names and addresses of individuals to whom supervisory evaluations will be sent:
______________________________________________________________________________
______________________________________________________________________________
Policy/ method supervisee will use to contact the clinical supervisor:
______________________________________________________________________________
Procedures supervisee will use to respond to client emergencies:
______________________________________________________________________________
PSYCHOTHERAPY LEARNING NEEDS ASSESSMENT:
Transcripts of supervisee’s academic courses (attached).
Current job description (attached).
Resume or list of prior professional experiences, responsibilities, and duties (attached).
Prior professional experience that is relevant to the supervisee’s current patient population:
______________________________________________________________________________
______________________________________________________________________________
Knowledge and skills supervisee acquired from previous professional training and experience
such as: diagnostic assessment and treatment; ethical standards of practice; state and federal laws
and rules; record keeping; cultural competence, e.g., knowledge and experience with cultural
norms of behavior for clients served by the supervisee (e.g., ethnicity, race, age, class, gender,
sexual orientation, religion, immigration status, literacy, and mental or physical disability);
commitment to maintaining cultural competence as an ongoing process; methods for establishing
treatment relationship with clients and patients; methods for including family members in
clients’ treatment when appropriate; communication with other professionals in developing
diagnosis and treatment plans and assuring continuity of care:
______________________________________________________________________________
______________________________________________________________________________
Professional strengths supervisee has that supervisee, teachers and former supervisors have
identified:
Professional weaknesses or concerns about supervisee’s practice that the supervisee, teachers and
former supervisors have identified:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Supervisee’s greatest sources of professional concerns and anxiety:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Supervisee’s specific learning needs, including skills supervisee needs to develop:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
How supervisee learns best:
______________________________________________________________________________
Learning barriers and accommodations, if any, needed: ______________________________
SUPERVISEE’S RIGHTS
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The right to have weekly (or other predictable frequency) supervisory sessions that will
focus on my learning needs and my clients’ treatment needs;
The right to understand and to participate in the development of my learning objectives,
activities to meet learning objectives, and standards for mastery of learning objectives;
The right to know my supervisor’s professional qualifications (training, licensure,
competencies, experience, education, treatment approach, biases, etc.);
The right to have regularly scheduled performance evaluations and to have my
performance evaluations sent in a timely manner to the appropriate institution (for
example, graduate school, regulatory board, employer);
The right not to be discriminated against in the provision of supervisory services on the
basis of my race, gender, ethnic origin, disability, creed, or sexual orientation;
The right not to be harassed or exploited to meet my supervisor’s personal needs;
SUPERVISEE’S RESPONSIBILITIES
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To collaborate with my psychotherapy supervisor in developing a learning needs
assessment and supervision plan;
To bring my psychotherapy cases, including records, to my clinical supervisor for honest
and direct discussion and review;
To provide my psychotherapy supervisor with access at any time to my patients’ records
for review;
To thoroughly present each of my clients’ cases verbally and in writing, including all
factors relevant to diagnosis and treatment, including but not limited to: presenting
problems; history of problems; significant childhood, family relationship, work, and other
life history; medical treatment; medications; past treatment; mental status observations;
diagnoses and treatment plans; my process of providing informed consent; my clinical
interventions, including attention to high risk or safety concerns; preventive action taken;
referrals; means of evaluating my clients’ progress, record keeping, and other
professional issues, including transference and counter transference.
To inform my patients of exceptions to confidentiality, including that my psychotherapy
supervisor will be discussing my sessions, reviewing case notes and electronic recordings
of patient sessions;
To obtain my patients’ informed consent in writing for any electronic recording of
sessions for purpose of supervision;
To read, understand, and adhere to my office’s and psychotherapy supervisor’s security
and privacy policies and procedures;
To follow state and federal laws and rules and professional ethical standards and to
discuss ethical and legal questions or other problems as they arise in each of my cases.
PSYCHOTHERAPY SUPERVISOR’S RESPONSIBILITIES
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To provide supervision appropriate to my supervisee’s professional needs and that meets
the requirements of professional ethics and state and federal laws and rules;
To schedule regular supervisory meetings with my supervisee and be available for
emergencies (or specify another supervisor available for emergencies);
To develop a learning needs assessment with my supervisee and establish clear learning
objectives and criteria for mastery of learning objectives;
To teach practical clinical skills, including the characteristics and contents of good
clinical records, and help my supervisee integrate theoretical knowledge with clinical
skills in order to develop professional competence;
To help my supervisee appropriately manage transference, counter transference, and
professional boundary issues;
To help my supervisee understand cultural norms;
To help my supervisee understand ethical standards;
To help my supervisee identify when a patient may have special problems that require
another professional’s consultation;
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To regularly assess and provide feedback on my supervisee’s progress, including
identification of strengths, weaknesses, and errors, and to work with my supervisee to
develop plans for improvement;
To conduct formal performance evaluations at 6-month intervals (or other predetermined
interval);
To honestly communicate my supervisee’s performance evaluation results, including
professional strengths as well as any unresolved practice errors or clinical and ethical
concerns, to those persons who require supervisee’s performance evaluation;
To meet and adhere to supervisor requirements of the (licensure board that regulates my
practice).
PSYCHOTHERAPY SUPERVISOR’S RIGHTS
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The right to information needed to provide appropriate supervision;
The right to be compensated promptly for supervision services as agreed upon and when
payment arrangement is applicable;
The right to provide supervision in an atmosphere free of verbal, physical, or sexual
harassment;
The right to terminate supervision when in my professional opinion it is not effective.
The right to determine terms and conditions of termination of supervision contract, which
are that this supervision contract may be terminated with two weeks written notice by
either party.
By signing, we agree that the above information is accurate and that we agree to follow the
terms, rights and responsibilities as outlined in the psychotherapy supervision contract.
Supervisee Signature: ______________________________
Date: ______________________________
Supervisor Signature: ______________________________
Date: ______________________________
Other Signature(s): ______________________________
Role: ______________________________
Date: ______________________________
Addendum for External Psychotherapy Supervision
(Occurring outside of training program or employment)
When the supervisor who is providing clinical supervision is not employed by the supervisee’s
place of employment or training program, there are additional considerations that the external
clinical supervisor needs to discuss with the supervisee and the professional staff within the
supervisee’s training program or place of employment. These may include the need to define the
external psychotherapy supervisor’s competence to supervise the cases from the training
program, agency or clinic etc.; the need to define respective supervisory responsibility and limits
of responsibility for the supervisee’s practice; methods for handling discrepant direction from
training supervisor or employer versus the external psychotherapy supervisor; confidentiality and
privacy; mandated reporting; performance issues.
The following can be discussed and agreement reached before beginning the supervisory
relationship:
Describe treatment modalities utilized/required by the training program, clinic, agency, etc.:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Describe treatment modality competencies held by the external psychotherapy supervisor:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Reason for referral to external psychotherapy supervisor:
Describe who has responsibility for the supervisee’s performance:
______________________________________________________________________________
Describe what information from supervisory communications will be shared with the training
program, agency, or clinic:
______________________________________________________________________________
Describe how conflict between agency and supervisor expectations will be negotiated:
______________________________________________________________________________
Describe how patients’ therapy records will be handled to protect patients’ privacy and
confidentiality:
______________________________________________________________________________
Describe exceptions to supervisee’s privacy and confidentiality:
______________________________________________________________________________
Identify the supervisor responsible for the supervisee at the place of training or employment and
their contact information:
Name: ______________________________________
Address: ____________________________________
Phone: ______________________________________
Email: ______________________________________
By signing this addendum, I give permission for my supervisor and employer or training
program to communicate on any issues that may create ethical or legal issues or practice
problems.
Supervisee’s Signature: ____________________________________Date: ______________
Supervisor’s Signature: ___________________________________Date: _______________
Name/title of staff member administratively responsible for supervisee at place of employment
Signature: ______________________________________________________ Date:_________