Submit form with application, email to email@example.com,
or mail to:
Form must be completed by the supervisor.
Applicant Name: ________________________________________________________________
Florida Intern Registration Number/Other State License Number: __________________________
Select profession: Clinical Social Work Marriage & Family Therapy Mental Health Counseling
1. SUPERVISOR INFORMATION
Supervisor Name: ____
Email Address: _______________________________________________________________________________
License Type State License Number
Supervisors licensed outside of Florida must provide a license verification
2. SUPERVISED CLINICAL EXPERIENCE
I have read and understand Rule 64B4-2, Florida Administrative Code (F.A.C.), which states, in part:
An intern shall be credited for the time of supervision required by s. 491.005, F.S., if the intern:
a) Received at least 100 hours of supervision in no less than 100 weeks; and
b) Provided at least 1500 hours of face-to-face psychotherapy with clients; and
c) Received at least one hour of supervision every two weeks
A. Dates of supervision: Start Date: ___________________ End Date: _____________________
MM/DD/YYYY Provide specific date - MM/DD/YYYY
B. The applicant received ___________ hours of supervision, with at least one hour of supervision every two weeks.
C. The applicant provided psychotherapy face-to-face with clients for a total of ___________ hours.
Select one of the following:
I intend to provide supervision until the registered intern is fully licensed pursuant to s. 491.0045(3),
F.A.C. If this changes, I will notify the board office of the date supervision ended.
I am no longer providing this registered intern with supervision as of: _____________________
3. SUPERVISOR STATEMENT
As the qualified supervisor of this intern, select the answer below that reflects your conclusion of their ability to
practice and/or counsel independently.
Has the applicant met the minimum standards of performance in professional activities as measured against generally
prevailing peer performance, pursuant to s. 491.009(1)(r), F.S.? Yes No
If “No,” you must provide further information to explain why this requirement has not been met.
Supervisor Signature: ___________________________________________________ Date: ____________________
DH-MQA 1174, Revised 8/2020, Rule 64B4-3.001, F.A.C.