Louisiana State Board of Social Work Examiners
18550 Highland Road, Suite B
Baton Rouge, LA 70809
Telephone: 225-756-3470 Fax: 225-756-3472
Toll-free in LA: 800-521-1941
The Record of Supervision is required for maintaining a written account of dates of supervision and time spent
in each session. Identifying client information should not be included when summarizing the major activities
and themes covered in supervision. Copies can be made as needed; however, the ORIGINAL Record of
Supervision is to be submitted to the board.
Supervisee:__________________________________________________________________________
(PRINT Name and Credential Number)
Supervisor:__________________________________________________________________________
(PRINT Name and Credential Number)
Date
Of
Session
(m/d/y)
Begin
& End
Time
Of
Session
Group
Or
Individual:
Indicate
w/ G or I
Major activities and themes covered
(To be completed by either supervisor or supervisee)
Signatures
(To be signed by both
supervisor & supervisee)
Page 1 of ____
Record of Supervision
Record of Supervision Page ____ of ____
Date
Of
Session
(m/d/y)
Begin
& End
Time
Of
Session
Group
Or
Individual:
Indicate
w/ G or I
Major activities and themes covered
(To be completed by either supervisor or supervisee)
Signatures
(To be signed by both
supervisor & supervisee)
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