Fillable Supervision Log Supervision Log (North Carolina Board of Licensed Clinical Mental Health Counselors)

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Supervision Log Supervision Log (North Carolina Board of Licensed Clinical Mental Health Counselors)

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Supervision Log Revised 01-7-20
Supervisor Name: License Type/Number:
LCMHC Associate Name:
LCMHC (# )
This form is being provided as a sample log for use by NCBLCMHC Board Approved Supervisors. Supervisors
may develop their own form as long as the required elements as defined in Rule .0208 are documented on the
log. This form is not required to be provided to the NCBLCMHC Board unless formally requested.
Dates – Start/Stop
Modality
Individual/Group
Direct/Indirect Hrs
Supervision Hrs
/
Live
Co-Therapy Audio Video
Individual
Group
/
Notes: (recommendation, interviews, etc.)
Dates – Start/Stop
Modality
Direct/Indirect Hrs
Supervision Hrs
Live Co-Therapy Audio Video
/
Notes: (recommendation, interviews, etc.)
Dates – Start/Stop
Modality
Individual/Group
Direct/Indirect Hrs
Supervision Hrs
/
Individual Group
/
Live
Co-Therapy Audio Video
Notes: (recommendation, interviews, etc.)
Dates – Start/Stop
Modality
Individual/Group
Direct/Indirect Hrs
Supervision Hrs
/
Individual
Group
/
Live Co-Therapy Audio Video
Notes: (recommendation, interviews, etc.)
Important Reminders:
•
A log of clinical supervision hours will be maintained that includes the date; supervision start and stop times; the modality of supervision
to be provided, such as live observation, co-therapy audio and video recordings, and live supervision, as defined by Rule .0208; and notes
on recommendations or interventions used during the supervision.
•
The supervisor shall be available for consultation with the Board or its committees regarding the supervisee’s competence.
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Supervision Log Supervision Log (North Carolina Board of Licensed Clinical Mental Health Counselors)

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Completed 4 September 2021

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