INSTRUCTIONS: FORMS MUST BE MAILED—NO FAXES OR EMAILS
1. PRINT or TYPE using BLACK Ink to complete this supervision contract.
2. ALL SECTIONS must be completed or the supervision contract will be returned.
3. The supervision contract should be mailed to the NCBLCMHC Board Office at: NCBLCMHC, PO Box
77819, Greensboro, NC 27417
I. GENERAL INFORMATION ‐ (Supervisor Information)
(LCMHC, LCSW, etc.)
Supervisor’s Name (Last, First, Middle):
License Type/Number:
Mailing Address (Name of Workplace, Mailing Address, City, State, Zip Code):
Issuance Date:
Business Phone:
Mobile Phone:
Email Address:
II.
SUPERVISION ‐ To be completed by supervisor. Clinical Supervision is defined in Rules .0208 through .0212.
Is this an exempt setting (school, university, government agency)?
Yes
No
Location of Supervision— provide name of workplace, physical address and a contact phone number:
Physical Address (Street, City, State, Zip Code):
Business Phone:
Modality of Supervision to be Used ‐ each supervision session shall utilize at least one of the following (check all that apply):
Live Observation/Supervision Co‐therapy Audio Recording
Video Recording
Frequency of Supervision (minimum one hour of individual or two hours of group supervision per 40 hours of counseling practice as defined in Rule .0208. At least
three‐quarters of the hours of clinical supervision shall be individual.):
The supervisee will receive a minimum of hours of individual clinical supervision weekly biweekly monthly or
a minimum of hours of group clinical supervision weekly biweekly monthly
III.
SUPERVISOR CREDENTIALING ‐ If proposed supervisor is a NC Licensed Clinical Mental Health Counselor Supervisor (LCMHCS), skip to
signatures.
The following documentation must be submitted with this Supervision Contract:
Official transcript documenting the equivalent of 3 semester graduate credits in clinical supervision from a regionally accredited institution
of higher education or 45 contact hours of continuing education in clinical supervision as defined by Rule .0603(c).
I agree to assume responsibility for the clinical work and preparation of this supervisee and will be available for consultation with the Board or
its committees regarding the supervisee’s competence.
Supervisor’s Signature: ______________________________________________________ ___
Date: __________________________
I understand and will abide by the requirements and expectations of supervision and the standards of clinical practice as defined by the Board.
Supervisee’s Signature: Date:
