PROOF
Other Work Activities
(Work-related activities have been briey dened within the application. The list below takes that identication into specic
activities and functions that an applicant may engage in as he/she works the program set out in the supervisory contract. They include any
activities that are not involved in face-to-face client contact and supervision that a permit holder might be reasonably expected to have
mastered in order to begin to practice independently. On the grid of 1 through 5, level 1 represents a beginning level of understanding
and implementing the activity. Level 5 represents the level of mastery anticipated for licensure and a beginning of independent practice.
If this rating is occurring at the completion of supervision with this supervisee, this rating should be nal.
1 2 3 4 5
Preparing a client le and structuring
the information to be
included in the record _____ _____ _____ _____ _____
Maintaining client notes _____ _____ _____ _____ _____
Preparing forms that meet H.P.P.A. requirements,
N.J. Statutory and Regulation standards:
Release of information forms _____ _____ _____ _____ _____
Client records and reports _____ _____ _____ _____ _____
Maintaining personal contact records _____ _____ _____ _____ _____
Security of clinical recordings (if any) _____ _____ _____ _____ _____
Careful disposal of trash _____ _____ _____ _____ _____
Preparing treatment plans _____ _____ _____ _____ _____
Writing reports _____ _____ _____ _____ _____
Preparing insurance forms _____ _____ _____ _____ _____
Maintaining appointment schedules _____ _____ _____ _____ _____
Communicating with referral sources _____ _____ _____ _____ _____
Communicating with other professionals _____ _____ _____ _____ _____
Preparing and maintaining nancial records _____ _____ _____ _____ _____
Preparing for supervision _____ _____ _____ _____ _____
Developing practice-related materials
A variety of forms that facilitate
the practice _____ _____ _____ _____ _____
Advertising materials _____ _____ _____ _____ _____
Business card _____ _____ _____ _____ _____
Letterhead _____ _____ _____ _____ _____
Announcements _____ _____ _____ _____ _____
Other materials _____ _____ _____ _____ _____
Other activities required by supervisor: specify
_______________ _____ _____ _____ _____ _____
_______________ _____ _____ _____ _____ _____
_______________ _____ _____ _____ _____ _____
I afrm the accuracy of this report:
Signature of Applicant: _____________________________________________________________________________
I have read the statute (N.J.S.A. 45.8b-1 et seq.) and regulations (N.J.A.C. 13:34-1.1 et seq.) that accompany this application.
Yes
No
Signature of Supervisor: _______________________________________________ Date: _________________________
I concur that the above report is accurate and recommend this applicant to continue in his or her training for licensure.
I do not recommend this applicant to continue in his or her training for licensure.
Comments: __________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
This Semi-Annual Report form is available on the Board’s Web site at:
www.njconsumeraffairs.com/medical/familytherapy.htm
You may print copies of it as needed.
Please make a copy of the Semi-Annual Report form for both the applicant’s and the supervisor’s records.
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