Fill - Free fillable Form 3.: FinalSupervisionRe o t p r INSTRUCTIONS:FORMSMUSTBEMAILEDNOFAXESOREMAILS (North Carolina Board of Licensed Clinical Mental Health Counselors) PDF form

FinalSupervisionRe

t

IndicatetowhichLCMHCAssociatethisﬁnalsupervisionreportapplies:

LCMHCAssociateName:

LCMHCA(#

)

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.

TheFinalSupervisionReportshouldbemailedinasealedenvelope,

signedacrossthesealedﬂap

,t othe

BoardOﬃceat:

NCBLCMHC,POBox77819,Greensboro,NC27417

BusinessPhone:

MobilePhone:

I. GENERALINFORMATION‐Supervisor’s InformaƟon. Supervisor’sName(Last,First,Middle):

MailingAddress(Streetand/orBoxNumber,City,State,ZipCode):

EmailAddress:

II. FINALSUPERVISION‐Tobecompletedbysupervisor. Dates must be entered to be considered complete.

SupervisionPeriod: BeginDate(mm/dd/yy)

EndDate(mm/dd/yy)

ModalityofSupervisionUsed(checkallthatapply):

LiveObservaon/Supervisi

onCo‐therapyAudioRecordingVideoRecording

SupervisedProfessionalPracceandClinicalSupervision:(Please enter total hours of supervision)

SupervisedProfessionalPracce(asdeﬁnedinRule.0208):

(nomorethan40perweek)

Total # Hours IndirectCounseling:

Total # Hours DirectCounseling:

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):  Total#Hours: (no less than 2hrs per 40 hrs worked)

III. SUPERVISIONSUMMARY‐Tobecompletedbysupervisor.Please provide a summary of the supervision acƟviƟes

completed with this supervisee as well as idenƟfy strengths and potenƟal deﬁcits of the supervisee. AƩach addiƟonal pages as needed.

Revised2/10/2020

Thisversionsupersedesallpreviousversions FinalSupervisionReport

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

1 2 3 4 5 6

Individualcounselingskills

Diagnoscski

lls

Treatmentpl

anningimplementa

on

Appropriatereferralmakin

g

Appropriaterecor

dkeeping

Groupcounselingskills

Personalintegrity

Consulngskills

Insightintocl

ient'sproblems

Abilitytorelatetoco‐workers



Abilitytobeobjecveonthejob

Knowledgeofassessmentinstrum

ents

Ethicalconduct

Concernforthewelfareofclients

Senseofresponsibility

Recogni

onofownlimits

Abilitytokeepmaterialconﬁdenal

Comments

V. REF

ERENCE‐To be completed by supervisor.

IrecommenddonotrecommendthisapplicantforunrestrictedlicensureasaNCLicensedClinical Mental Health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hou

rofindividualor2hoursofgroupclinicalsupervi‐

sionper40hoursofcounselingpracce.

Supervisor’sSignature: Date:

Aercomplengthisform,pleaseencloseitinasealedenvelope,signacrossthesealedﬂap,andreturnto

theNCBoardofLicensedClinical Mental HealthCounselors.

Page2of2

click to sign

signature

click to edit

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

Form 3.: FinalSupervisionRe o t p r INSTRUCTIONS:FORMSMUSTBEMAILEDNOFAXESOREMAILS (North Carolina Board of Licensed Clinical Mental Health Counselors)

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank Form 3.: FinalSupervisionRe o t p r INSTRUCTIONS:FORMSMUSTBEMAILEDNOFAXESOREMAILS (North Carolina Board of Licensed Clinical Mental Health Counselors) Form

Related forms

Fillable Form 3.: FinalSupervisionRe o t p r INSTRUCTIONS:FORMSMUSTBEMAILEDNOFAXESOREMAILS (North Carolina Board of Licensed Clinical Mental Health Counselors)

Fill Online, Printable, Fillable, Blank Form 3.: FinalSupervisionRe o t p r INSTRUCTIONS:FORMSMUSTBEMAILEDNOFAXESOREMAILS (North Carolina Board of Licensed Clinical Mental Health Counselors) Form

Related forms

First 20 documents completely FREE!