BeginDatemmddyy 2020-2026
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The Final Supervision Report should be mailed in a sealed envelope signed across the sealed flap to the Board O ce at NCBLPC PO Box 77819 Greensboro NC 27417 I. Final Supervision Report Indicate to which LPC Associate this final supervision report applies LPC Associate Name LPCA 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. 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. Supervision Period Begin Date mm/dd/yy Dates must be entered to be considered complete. 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 Total Hours Indirect Counseling Total Hours Direct Counseling no more than 40 per week 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 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. A ach addi onal pages as needed* This version supersedes all previous versions Revised 10/25/2017 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 Comments Individual counseling skills Diagnos c skills Treatment planning implementa on Appropriate referral making 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 Professional 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.
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Understanding the supervision report form counselors get
The supervision report form counselors get is a crucial document used in the counseling profession, particularly in North Carolina. This form serves as a record of the supervisory relationship between a counselor and their supervisor. It includes essential details such as the dates of supervision, the topics discussed, and the overall progress of the counselor. Proper completion of this form is vital for compliance with state regulations and ensures that counselors are meeting the necessary requirements for licensure.
Steps to complete the supervision report form counselors get
Completing the supervision report form requires careful attention to detail. Here are the steps to ensure accurate completion:
- Gather necessary information: Collect all relevant details, including the counselor's name, supervisor's name, and the dates of supervision sessions.
- Document supervision sessions: Record the topics discussed during each session, noting any specific feedback or guidance provided by the supervisor.
- Evaluate progress: Include an assessment of the counselor's development and any goals set for future sessions.
- Sign and date: Both the counselor and supervisor should sign and date the form to validate its authenticity.
Legal use of the supervision report form counselors get
The legal validity of the supervision report form counselors get hinges on compliance with relevant laws and regulations. In the United States, e-signatures are recognized as legally binding under the ESIGN Act and UETA. This means that when using a digital platform to complete and sign the form, it is essential to ensure that the platform complies with these legal standards. Adhering to these regulations helps protect the integrity of the document and the confidentiality of the information contained within.
Key elements of the supervision report form counselors get
Several key elements must be included in the supervision report form counselors get to ensure it serves its purpose effectively:
- Identifying information: Names and contact information for both the counselor and the supervisor.
- Session details: Dates and times of supervision sessions, along with a summary of each session's content.
- Goals and objectives: Clearly defined goals for the counselor's development and any specific areas of focus.
- Signatures: Required signatures from both the counselor and supervisor to confirm the accuracy of the information provided.
Examples of using the supervision report form counselors get
Practical examples of how the supervision report form counselors get can be utilized include:
- Licensure applications: Counselors may need to submit this form as part of their application for licensure to demonstrate their supervised experience.
- Continuing education requirements: Some states require counselors to provide documentation of supervision as part of their continuing education credits.
- Performance evaluations: Supervisors may use the information from these forms to evaluate the counselor's performance and provide constructive feedback.
Form submission methods for the supervision report form counselors get
The supervision report form counselors get can be submitted through various methods, depending on the requirements of the supervising body. Common submission methods include:
- Online submission: Many organizations now accept digital submissions, allowing counselors to complete and submit the form electronically.
- Mail: Counselors may opt to print the completed form and send it via postal mail to the appropriate licensing board or organization.
- In-person delivery: Some counselors may choose to hand-deliver the form to ensure it reaches the intended recipient directly.
Quick guide on how to complete begindatemmddyy
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| NC Final Supervision Report 2020 | 4.8 Satisfied (1908 Votes) | |
| NC Final Supervision Report 2019 | 4.8 Satisfied (173 Votes) | |
| NC Final Supervision Report 2017 | 4.8 Satisfied (1096 Votes) | |
| NC Final Supervision Report 2010 | 4.7 Satisfied (343 Votes) | |
| IRS W-9 2020 | 4.8 Satisfied (346 Votes) | |
| IRS W-9 2019 | 4.8 Satisfied (346 Votes) |
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