Fillable I. GENERAL INFORMATION - To be completed by (North Carolina Board of Licensed Clinical Mental Health Counselors)

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I. GENERAL INFORMATION - To be completed by (North Carolina Board of Licensed Clinical Mental Health Counselors)

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VERIFICATION OF SUPERVISED PROFESSIONAL PRACTICE INSTRUCTIONS
1. PRINT or TYPE using BLACK Ink to complete this verification of supervised professional practice. Person verifying supervised professional practice
must be a qualified clinical supervisor as defined in Rule .0209.
2. ALL SECTIONS must be completed or the verification of supervised professional practice will be returned.
3. The verification of supervised professional practice should be enclosed in a sealed envelope and signed across the flap. Mail the signed and
sealed envelope to the NCBLCMHC Board Office at: NCBLCMHC, PO Box 77819, Greensboro, NC 27417
Indicate to which Applicant this supervised professional pracce form applies:
Name: _________________________________________________________________________
I. GENERAL INFORMATION - To be completed by person verifying supervised professional pracce.
Supervisor’s Name (Last, First, Middle):
Title:
Name of Agency where Supervised Professional Pracce occurred: License Type and Number:
Mailing Address (Street and/or Box Number, City, State, Zip Code): Issue Date:
Business Phone:
Em
ail Address:
II. SUPERVISED PROFESSIONAL PRACTICE-
Supervision Period: (month/date/year) to (month/date/year)
Modality of Supervision Used (check all that apply):
Direct (Live) Observaon/Supervision Co-therapy Audio Recording Video Recording
Su
pervised Professional Pracce and Clinical Supervision:
Supervised Professional Pracce (as dened in Rule .0208): Total # Hours Indirect Counseling:
(no more than 40 per week) Total # Hours Direct Counseling:
Individual Clinical Supervision (as dened in Rule .0210): Total # Hours: (no less than 1hr per 40 hrs worked)
Group Clinical Supervision (as dened 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 acvies completed with
this supervisee as well as idenfy strengths and potenal decits of the supervisee. Aach addional pages as needed.


CMH
Revised 2/10/2020This version supersedes all previous versions Verification of Supervised Professional Practice
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 Qualied 6 = Cannot Evaluate
1 2 3 4 5 6 C
omments
Individual counseling skills
Diagnosc skills
Treatment planning implementaon
Appropriate referral making
Appropriate record keeping
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 condenal
V. REFERENCE - 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 application 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.
S
upervisor’s Signature: Date:
After completing 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.
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I. GENERAL INFORMATION - To be completed by (North Carolina Board of Licensed Clinical Mental Health Counselors)

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Completed 4 September 2021

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