Fillable Proposed Plan of Supervised Counseling Experience (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Proposed Plan of Supervised Counseling Experience (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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  • 30 check-boxes
  • 46 other fields

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Marriage and Family Therapy Examiners
Professional Counselor Examiners Committee
124 Halsey Street, 6th Floor, P.O. Box 45044
Newark, New Jersey 07101
(973) 504-6582
Proposed Plan of Supervised Counseling Experience
(This form should be completed by the supervisor and forwarded directly to the Committee.)
Please print clearly.
Name of applicant:____________________________________________________________________________________________
Last name First name Middle initial
Applicant’s address:___________________________________________________________________________________________
Street or P.O. Box City State ZIP code
Associate Counselor license number: __________________________________________
Supervisor’s Information
___________________________________________________________________________________________________________
Last name First name Middle initial Other names if applicable
Business name: _______________________________________________________________________________________________
Type of business (nonprot, for prot, group, private, etc.)
____________________________________________________________________________________________________________
Business address
____________________________________________________________________________________________________________
City State ZIP code
Telephone number: _______________________________________ E-mail address:_______________________________________
(include area code)
(1) YOU [THE SUPERVISOR] MUST ATTACH YOUR CURRENT RESUME/CURRICULUM VITAE, A COPY OF THE
SUPERVISORY CREDENTIAL, and
(2) OFFICIAL JOB DESCRIPTION FOR THE ASSOCIATE COUNSELOR.
(3) PURSUANT TO N.J.A.C. 13:34-13.1(c) THE WRITTEN SUPERVISION PLAN SHALL BE APPROVED BY THE
COMMITTEE PRIOR TO THE PERFORAMANCE OF COUNSELING BY THE ASSOCIATE COUNSELOR.
Qualied supervisor: N.J.A.C. 13:34-10.2 and 13.1(a) (Check all that apply.)
ACS (NBCC-Issued) Three (3) graduate credits: Clinical Supervision
Other: _____________________
(Attach ofcial verication for area(s) you checked.)
Licensure of supervisor: (Check all that apply.)
Completed a minimum of 2 years’ (3,000 hours) experience as licensed (checked below):
Marriage and Family Therapist Professional Counselor
Licensed Clinical Social Worker
Psychologist
Psychiatrist
Rehabilitation Counselor
Other: ______________________________________________________
____________________________________________________________________________________________________________
Type of license or certicate Number State or jurisdiction issuing license or certicate Date of initial issue/expired
____________________________________________________________________________________________________________
Type of license or certicate Number State or jurisdiction issuing license or certicate Date of initial issue/expired
____________________________________________________________________________________________________________
Type of license or certicate Number State or jurisdiction issuing license or certicate Date of initial issue/expired
____________________________________________________________________________________________________________
Type of license or certicate Number State or jurisdiction issuing license or certicate Date of initial issue/expired
1. Have any of the supervisor’s licenses ever been suspended, revoked or restricted?
Yes
No
If “Yes,” attach documentation and an explanation to this form.
2. Where will client contact and supervision take place?
_______________________________________________________________________________________________________
Agency name Address Telephone number (include area code)
Agency tax status: For-prot Not-for-prot
For Ofcial Use Only
Approved:
Yes No
Date: ___________________
3. Graduate school attended: __________________________________________________________________________________
Major: ________________________________________ Highest degree earned: _____________________________________
4. Is there any circumstance that precludes your objective assessment of the applicant? Yes No
If “Yes,” please explain on a separate sheet of paper. N.J.A.C. 13:34-13.1 (Examples: current and former clients,
current employers (employees may not supervise employers), relatives of the supervisor, relatives of current clients,
current students or close friends.)
5. N.J.A.C. 13:34-13.1(g)
Prior to the treatment of each client, supervisors are required to obtain a written disclosure that is: easily readable, clearly
understood, signed by the client and retained in the client’s record. The disclosure must also acknowledge notice that
services are to be rendered by an associate counselor under the supervision of a qualied supervisor.
6.
Does the proposed supervisor have any other individuals under clinical supervision? (See N.J.A.C. 13:34-3.1(f).)
Yes No
If “Yes,” provide the names of the other individuals and the total number of supervisees:
____________________________________________________________________ .
7. What is the proposed number of direct client contact hours you plan to meet WEEKLY? (See N.J.A.C. 13:34-10.2, “One Calendar
Year” means a maximum of 1,500 hours/year, 125 hours/month, 30 hours/week.)
Couples_________ Families________ Individuals_________ Groups________
8. What is the proposed number of hours of supervision you plan to meet WEEKLY?
Individual or Dyad (two people)____________ Group_____________
(N.J.A.C. 13:34-10.2 requires at least 50 hours of face-to-face supervision per one calendar year at the rate of one hour per week,
of which not more than 10 hours may be group supervision.)
9. What are the inclusive dates with the above supervisor? Beginning: ____________ Anticipated Ending: _____________
month/day/year month/day/year
10. Type of supervisory modalities to be utilized: (See N.J.A.C. 13:34-13.1(b) and check all that apply. At least one must apply.)
Note the supervision requirements at N.J.A.C. 13:34-13.1(b), (c) and (d)1, 2 and 3.
Audiotape
Videotape
Session observation/Live supervision
11.
Do you agree to maintain weekly supervision notes which will be made available to the Committee upon request?
Yes No
12. Describe the proposed client services you are contracting to provide, pursuant to N.J.A.C. 13:34-10.2 (please include the
applicant’s detailed job description). (Add separate pages as needed.)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
13. Has the applicant read the statutes and regulations of New Jersey that govern the practice of professional counseling?
Yes
No
(N.J.S.A. 45:8B-34 et seq. and N.J.A.C. 13:34-10.1 through 31.8)
14. Has the supervisor read the pertinent statutes and regulations of New Jersey?
Yes
No
(N.J.S.A. 45:8B-34 et seq. and N.J.A.C. 13:34-10.1 through 31.8)
15. Accordingtoyourunderstanding,whatarethepersonallearningobjectivesofthesupervisee?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
16. Toyourknowledge,willthesuperviseehavemorethanonesupervisorintheaboveoranothersettingduringtheinclusivedates?
 

Yes
No
If“Yes,”pleaseadvisethesuperviseetorequestthataseparateformbesubmittedbythatsupervisor.
____________________________________________________________________________________________________

Applicant’ssignatureProposedsupervisor’ssignatureDate
THE SUPERVISOR IS REQUIRED TO IMMEDIATELY NOTIFY THE PROFESSIONAL COUNSELOR EXAMINERS
COMMITTEE OF ANY CHANGES IN THE EMPLOYMENT OF EITHER THE APPLICANT OR THE SUPERVISOR.
Certication
Icertifythatalloftheforegoinginformationprovidedhereinistrueandifanyinformationprovidedbymeiswillfullyfalse,Iamsubject
topunishment.
Supervisor’ssignature:____________________________________________________________Date:________________________
PleasesubmitthefollowingwiththecompletedPlan:
1.SupervisorResume
2.CopyofSupervisorycredential
3.AssociateCounselor’sOfcialjobdescriptiononagency/practiceletterheadpursuanttoN.J.A.C.13:34-10.2
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Proposed Plan of Supervised Counseling Experience (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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