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I have supervised masters level counseling interns in the community mental health,
residential, and inpatient psychiatric settings. I am currently enrolled in ECD 847:
Practicum in Counseling Supervision. While completing this 3 credit course, I will
receive supervision from my university instructor as I assist you in reaching your
counseling goals. Additionally, I also receive on-going clinical supervision as part of my
professional counseling responsibilities in the work place.
SUPERVISION ARRANGEMENTS
We agree to meet on the following day and time: __________________________________
ACKNOWLEDGEMENT
I have read the above statement in its entirety. I am informed about the policy
regarding supervision, confidentiality, and the limits of that confidentiality. With full
understanding of these provisions, I give my informed consent to receive supervision
services.
Supervisor Signature _____________________________
Date_______________
Date _________________