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Agency Letterhead
(To be completed by Supervisee)
Weekly/Bi-Weekly Clinical Supervision

Supervisee: _______________________________________

Supervisor:_______________________________________

Topics discussed:
Duties & Comprehensive Cases & Information &
expectations skills evaluation Assessment referral
Professionalism Process recording High Risk issues Evaluation issues
Judgment Decision making Progress notes Termination
Communication Problem solving Goals & objectives Diversity issues
skills
Counseling topics Initiative Practice/Intervention Mezzo practice
& deadlines skills issues
Attitude Flexibility Crisis intervention Macro practice
issues
Time Self-awareness Treatment planning Ethical issues
management
Learning plan Accountability Specific ACA Other:
techniques

Comments:

Supervisee Strengths:

Challenges:

Tasks to be completed by the next supervision session or date specified:

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Supervisee Signature: _____________________ Date ________________

Supervisee Signature: _____________________ Date ________________

Template provided by Supervisionary, LLC 2019