DOPL • Heber M. Wells Building • 160 East 300 South • P.O. Box 146741, Salt Lake City, UT 84114-6741
www.dopl.utah.gov telephone (801) 530-6628 • toll-free in Utah (866) 275-3675 • fax (801) 530-6511
Supervision for Post-Graduate Practice Hours
Use this form to track your supervision as a CSUDC OR CASUDC. Total of all hours must be at least 2,000 for LSUDC and 4,000 for LASUDC.
Do not
turn this form in with your CSUDC/CASUDC application. It should be turned in with your LSUDC OR LASUDC application.
SUPERVISEE INFORMATION
Full Legal Name:
License Number:
Email:
First
Middle
Last
SUPERVISED HOURS
Supervised Hours. Use additional sheets as needed.
Supervisor
Dates Supervised
(MM/DD/YYYY to MM/DD/YYYY)
Total Hours
Hours of Direct
Supervision
Supervisor’s Signature
to
to
to
Total from all supervisors:
Please list each supervisory meeting. Use additional sheets as needed.
Location
Format
(Individual, small group, etc.)
Supervisor
Supervisor Evaluation (use additional sheets if needed)
Signat
ure of Supervisee: ______________________________________________ Date: ______________________
F-60dSUD-Hrs
20210428
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