Fillable Documentation of Supervised Counseling Experience (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Documentation of Supervised Counseling Experience (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Marriage and Family Therapy Examiners
Professional Counselor Examiners Committee
124 Halsey Street, 6th Floor, P.O. Box 45044
Newark, New Jersey 07101
(973) 504-6582
Documentation of Supervised Counseling Experience
(This form should be completed by the supervisor and forwarded directly to the Committee.)
Information about the applicant
____________________________________________________________________________________________________
Lastname Firstname Middleinitial Maidenname(ifapplicable)
____________________________________________________________________________________________________
Streetaddress City State ZIPcode
__________________________________________________ ______________________________________________
Telephonenumber(includeareacode) E-mailaddress
Information about the supervisor
____________________________________________________________________________________________________
Lastname Firstname Middleinitial Maidenname(ifapplicable)
____________________________________________________________________________________________________
Streetaddress City State ZIPcode
__________________________________________________ ______________________________________________
Telephonenumber(includeareacode) E-mailaddress
__________________________________________________
LicenseorApplicationNumber
Please note:Thesupervisormustholdaclinicallicenseinamentalhealth-relateddiscipline.
Qualied supervisor: N.J.A.C. 13:34-10.2 and 13.1(a) (Check all that apply.) (For Licensed Professional Counselors Only)
(Attach ofcial verication for area(s) you checked.)
ACS(NBCC-Issued) Three(3)graduatecredits:ClinicalSupervision 
Other:_____________________
1. Doyouholdaclinicalmentalhealth-relatedprofessionallicenseintheStateofNewJersey? Yes No
If“Yes,”checktheappropriatebox.
Psychiatrist MarriageandFamilyTherapist RehabilitationCounselor
Psychologist ProfessionalCounselor ClinicalSocialWorker
Other:_________________________________________________
Yearlicensed:_______________ Licensenumber: __________________
2. Doyouholdaprofessionallicenseinanyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?
Yes No
If“Yes,”checktheappropriatebox.
CONTACT THE ISSUING LICENSING BOARD TO OBTAIN AN OFFICIAL LETTER OF GOOD STANDING.
Psychiatrist MarriageandFamilyTherapist ClinicalSocialWorker
Physician RehabilitationCounselor Other:________________________
ProfessionalCounselor Psychologist
Yearlicensed:_______________ Licensenumber: __________________ Stateoflicensure:_______________
for: LicensedProfessionalCounselorCandidate
LicensedRehabilitationCounselorCandidate
Pleaseprintclearly.
For Ofcial Use Only
Approved:

Yes No
Date:___________________
3. Graduateschoolattended: ___________________________________________________________________________
Major:______________________________________Highestdegreeearned:__________________________________
4. Isthereanycircumstancethatprecludesyourobjectiveassessmentoftheapplicant?  Yes No
If “Yes,” please explain on a separate sheet of paper. N.J.A.C. 13:34-13.1 (Examples: current and former clients,
current employers (employees may not supervise employers), relatives of the supervisor,relatives of current clients,
currentstudentsorclosefriends.)
The information requested below concerns the setting in which the applicant received his or her supervised experience.
____________________________________________________________ Tax status: for-prot not-for-prot

Nameofsetting
____________________________________________________________________________________________________
Streetaddress City State ZIPcode Telephonenumber(includeareacode)
1. Applicant’stitle(ifany)duringthetimeIsupervisedhimorher:_____________________________________________
2. Inclusivedatesofthesupervision:_______________________________ __________________________________
Datesupervisionstarted Datesupervisionended
(SeeN.J.A.C.13:34-10.2,“OneCalendarYear”meansamaximumof1,500hours/year,125hours/month,30hours/week.)
3. Totalnumberofsupervisedcounselingorrehabilitationcounselinghourscompletedbytheapplicantundermy
supervision:___________________
4. AveragenumberofhoursperweekIspentwiththeapplicantinface-to-facesupervision:__________
5. AveragenumberofhoursperweekIspentwiththeapplicantingroupsupervision:____________
6. Iperformedatleastoneofthefollowingactivitiesthroughoutthecourseofsupervision.Checkallthatapply.
(SeeN.J.A.C.13:34-13.1(d)1)
Iworkedasaco-counselorwiththeapplicant.
Iobservedtheapplicant’ssessionswithclients.
Iviewedvideotapesoftheapplicant’ssessionswithclients.
Ilistenedtoaudiotapesoftheapplicant’ssessionswithclients.
7. Iperformedatleastoneofthefollowingactivitiesthroughoutthecourseofsupervision.Checkallthatapply.
(SeeN.J.A.C.13:34-13.1(d)2)
Ireactedtocasepresentationsgivenbytheapplicant.
Iconductedrole-playingsessionswiththeapplicant.
8. Iperformedallofthefollowingactivitiesthroughoutthecourseofsupervision.Checkallthatapply.
(SeeN.J.A.C.13:34-13.1(d)3)
Iengagedinproblem-solvingdiscussionswiththeapplicantregardingindividualclients.
Ienteredintoproblem-solvingdiscussionsconcerningtheapplicant’sownproblems,insofarassuchproblemswere
affectingtheapplicant’sworkwithclients.
Iofferedfeedbacktotheapplicantregardingspecicinterventionsutilizedwithaclient.
Iofferedfeedbackconcerningtheapplicant’spersonalqualitiesastheyaffectworkwithclients.
Iofferedfeedbacktotheapplicantregardingthesupervisionexperience.
Other(pleasebespecic) ________________________________________________________________________
__________________________________________________________________________________________
DidyoumaintainweeklysupervisionnoteswhichwillbemadeavailabletotheCommitteeuponrequest?
 Yes No
9.Services provided by supervisee: (SeeN.J.A.C.13:34-10.2andcheckallthatareapplicable.)
Clinicallyassessandevaluatemental,emotional,behavorialandassociateddistresses
Conductassessmentsandevaluationsforthepurposeofestablishingtreatmentgoalsandobjectives
Plan,implementandevaluatecounselinginterventions
10.Counseling procedures implemented by supervisee: (SeeN.J.A.C.13:34-10.2andcheckallthatareapplicable.)
Appraisalandassessment
Counseling
Consulting
Referral
Research
11.Supervisor’s conclusions and recommendations
ThisapplicantisseekingtobecomeaLicensedProfessionalCounselororaLicensedRehabilitationCounselorinNewJersey.
Bythisapplication,theapplicantisclaimingreadinessforunsupervised,independentprofessionalpracticeandreadinessas
aclinicalsupervisor.Inassessingtheapplicant’sprofessionalreadiness,youarenowbeingaskediftheapplicantpossesses
thefollowingabilitiesandknowledge.
Theabilitytoestablishacounselingrelationship. Yes No Notobserved
Theabilitytoassessaclient’sneedsandtoplanappropriateinterventions. Yes No Notobserved
Theabilitytomakeinterventionsappropriatetoclientneeds. Yes No Notobserved
Theabilitytobeexibleinchoosingandchanginginterventionsasappropriate. Yes No Notobserved
Theabilitytoassessprudentlyone’sowncapacitiesandskillsinaprofessional
situation. Yes No Notobserved
Theabilitytoworkeffectivelyinaone-to-onerelationship. Yes No Notobserved
Theabilitytoworkeffectivelywheresystems-levelinterventionsarerequired. Yes No Notobserved
Theapplicantdemonstratesethicalbehavior. Yes No Notobserved
12. On a separate sheet of paper, please assess the applicant’s current state of preparedness for licensure. Also, please make
a recommendation regarding the applicant’s further professional development. Your recommendations are an
important element in the Committee’s overall evaluation of the applicant’s qualications for licensure.
13. Irecommendtheapplicantforlicensureatthistime.
Idonotrecommendtheapplicantforlicensureatthistime.(Please explain in details why in the comment section
below.)
Certication
Icertifythatalloftheforegoinginformationprovidedhereinistrueandifanyinformationprovidedbymeiswillfullyfalse,
Iamsubjecttopunishment.
_______________________________________________________________________________________________

SignatureofsupervisorDate
Comments: ____________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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Documentation of Supervised Counseling Experience (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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