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FORM #7: ASSOCIATE SUPERVISED CLINICAL EXPERIENCE PLAN (Oregon)

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Oregon Board of Licen
sed Professional Counselors & Therapists
FORM #7: ASSOCIATE SUPERVISED CLINICAL EXPERIENCE PLAN
As part of your Initial Application, attach a Professional Disclosure Statement (PDS) for each
employer/practice. Plans will not be approved until the PDS(s) are received.
For Associate Plan Change Requests, adding or removing supervisors, attach a revised
Professional Disclosure Statement for each employer/practice.
Applicant Name: ________________________________________________________________
Profess
ional Counselor Associate
Marriage & Family Therapist Associate
1. SETTING – Location(s) applicant’s employer/prac
tice site:
LOCATION 1
Agency Nam
e:
Location Address:
Mailing Address or PO Box:
City / State / Zip:
Telephone:
E-mail:
LOCATION 2
Agency Name:
Location Address:
Mailing Address or PO Box:
City / State / Zip:
Telephone:
E-mail:
2. SUPERVISION REQUIRED
Supervision is
required every month. The minimum level of supervision depends on the number of hours
accrued in a month. If the number of client contact hours in any given month is less than 46 hours, then the
minimum supervision requirement is two (2) hours, with a minimum of one (1) hour of individual supervision.
If the number of client contact hours in any given month is 46 hours or more, then the minimum supervision
requirement is three (3) hours of supervision, with a minimum of one and a half (1
1/2
) hours of individual
supervision. You can exceed the minimum level of supervision per month. If you do not meet minimum
monthly supervision requirements, then the client contact hours for the month will not be approved.
Provide a brief descriptio
n of clients and counseling activities to be performed. Activities must include
assessment, diagnosis and treatment of your clients:
_________________________________________________________________________________
Associate Clinical Experience Plan Page 1 of 4
Registration Type:
3. CLINICAL SUPERVISOR INFORMATION -
- TO BE COMPLETED BY PROPOSED SUPERVISOR
Supervisor:
Name:
Busi
ness Address:
Phone: E-mail:
Supervisor’s Mental Health Graduate Degree(s):
School:
Degr
ee:
Issu
ed
School:
Degree: Issued
How long have you known the applicant? years
months Describe pre-existent relationship.
_____________________________________________________________________________________
Are y
ou related to the applicant? Yes No
Have you ever been disciplined by any regulatory board? Yes No
If applicant is seeking registration as a marriage & family therapist associate, please list graduate-
level training in systemic theory and approach to couples and families issues:
______________________________________________________________________________________________________
Supervisor’s Clinical Experience in counseling or marriage & family therapy:
Number of ye
ars licensed in Oregon: _____
Approved Supervisor/Candidate on the OBLPCT Supervisor Registry (LPC/LMFT only): Yes No
Supervisor’s
State License / National Credential:
License Title Is
sued by [state or national org.]
License No
Original issue
date
Expiration date
License Title Issued by [state or national org.]
License No
Original issue
date
Expiration date
Associate Clinical Experience Plan
Page 2 of 4
4. SUPERVISION TRAINING.
Comple
ted 30 clock hours of post-masters training in supervision theory and practice through
workshops, or academic coursework, or completed the necessary requirements to be an AAMFT
approved supervisor, NBCC approved clinical supervisor, or an APCA diplomate. List coursework,
workshops, seminars, or national accreditation:
Title of class / workshop / seminars
National Accreditation
Sponsor of
program Date taken No. of
clock hrs
SUPERVISOR AGREES TO:
Supervision:
• Ensure compliance with Board’s current Oregon Administrative Rules.
• Provide ongoing, clinical supervision in a professional setting.
• Ensure that supervision of the supervisee is conducted face-to-face or through live, synchronous
confidential electronic communication.
• Discuss and review case notes, charts, records, and available audio or video for all clients with
the registered associate.
• Review and closely supervise the registered associate and all problem cases, providing special
attention to assessments, diagnosis, treatment planning, ongoing case management, emergency
intervention, record keeping, and termination.
• Focus on the appropriateness of the treatment plans and monitor the appropriateness of clients
served based on the registered associate's therapeutic skill. Direct the registered associate to
refer clients who fall beyond their level of competence.
• Maintain confidentiality of all client and supervisory materials.
• Review the Oregon licensing laws (ORS 675.705 – 675.835), administrative rules (OAR 833), and
Code of Ethics (OAR 833, Division 100) with registered associate.
• Ensure the registered associate is using an appropriate title and including the supervisor's name
and designation as "supervisor."
• Promptly notify the Board there are ethical concerns regarding the registered associate.
Reporting
:
• Establish and maintain a record-keeping system to track the direct client contact and supervision
hours. Supervisor will be prepared to provide supporting documentation verifying the accurac
y of
information reported, if requested by Board.
• Ensure that the Six-month Registered Associate Supervisor Evaluation and Reported Hours are
submitted to the Board within one-month of the end of the reporting period.
• Notify the Board of any changes to supervisor’s business address and phone number or change
in credential status.
• Notify the Board of any interruption or proposed termination of the plan.
Associate Clinical Experience Plan
Page 3 of 4
REGISTERED ASSOCIATE AGREES TO:
• Abide by the Code of Ethics for Counselors and Therapists as specifie
d in OAR 833, Division
100 and Oregon law and rules for LPCs and LMFTs.
• Distribute Professional Disclosure Statements to clients at the onset of therapeutic services.
• Establish and maintain a record keeping system to track the direct client contact and
supervision hours.
• Submit requests to modify this plan to the Board and receive approval prior to implementing
changes.
• Ensure supervisor has authority to review all records, determine appropriateness of records,
direct referrals of inappropriate clients, determine caseload, and report to Board.
TERMINATION OF ASSOCIATE REGISTRATION
Associate registration may be terminated (and licensure application closed) for the
following reasons:
• Failure to obtain prior approval of the Board for changes in plan terms: place of practice[s];
supervisor[s], including license/certification status; and level of supervision.
• Failure
to file a replacement plan within 90 days of the termination of supervisor.
• Failure to file a replacement plan within 90 days of the termination of a place of practice/
employment.
• Failure to submit a Registered Associate Six-Month Supervisor Evaluation & Hours Report.
• Failure to notify or file a replacement plan after placing internship on a 90-day hold.
• Failure to renew registration.
• Voluntary resignation or withdrawal of application.
• Exceeding five years from initial date of registration.
CERTIFICATION / SIGNATURES
I certify that the informatio
n provided in this document is true and correct to the best of my knowledge. I
agree to follow the provisions set forth in this plan. I understand my responsibilities. I understand that
k
nowingly making a false statement in connection with this proposed plan may result in disciplinary
action. I have been given a copy of this Associate Supervised Work Plan, Pages 1 - 4.
______________________________________________________ _________________________
Signature of Applicant Date
_____________________________________________________ __________________________
Signature Cliniof cal Supervisor Date
Instructions for Submitting Completed Form
Provide copies of this form for all signatories.
Submit this form, via the Board's Portal, with original signatures and a Professional Disclosure
Statement for each work location.
Receive notification from the Board that the Plan has been approved before beginning practice.
Associate Clinical Experience Plan
Page 4 of 4
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FORM 7: ASSOCIATE SUPERVISED CLINICAL EXPERIENCE PLAN (Oregon)

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Completed 20 April 2022

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