Fillable Verification of Supervision for Post-Graduate Mental Health Practice (Utah DRE)

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Verification of Supervision for Post-Graduate Mental Health Practice (Utah DRE)

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The Verification of Supervision for Post-Graduate Mental Health Practice (Utah DRE) form is 1 page long and contains:

  • 2 signatures
  • 5 check-boxes
  • 27 other fields

Country of origin: US
File type: PDF

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Utah Division of Real Estate (DRE) aims to protect the public and promote responsible business practices through education, licensure, and regulation of real estate, mortgage, and appraisal professionals

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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
Verification of Supervision for Post-Graduate Mental Health
Practice Hours
SUPERVISEE INFORMATION
To be completed by the supervisee.
Full Legal Name:
First
Middle
Last
Mailing Address:
Street/PO Box
City
State/Zip
License Number:
License Type:
SUPERVISOR INFORMATION
To be completed by the supervisor.
Full Legal Name:
First
Middle
Last
Mailing Address:
Street/PO Box
City
State/Zip
License Number:
License Type:
Issue Date*
*Proposed supervisors must have been actively engaged in licensed practice for at least 2 years before supervising post-graduate hours.
For Supervisors of AMFT’s: Please indicate which of the following you have completed in accordance with Utah Admin
Code R156-60b-302d(3).
Currently approved by AAMFT as an MFT supervisor.
Successfully completed a supervision course in a COAMFTE accredited MFT program at an accredited
university.
Successfully completed 20 clock hours of instruction sponsored by AAMFT or the Utah Association for
Marriage and Family Therapy.
For all license types:
I certify I have read Utah Admin. Code R156-60-302. Supervised Training Requirements-Supervision
Contract-Duties and Responsibilities of Supervisor and Supervisee. I understand that hours must be
documented using the Division provided Post-Graduate Mental Health Supervised Hours form.
Signature of Supervisor: ______________________________________________ Date: _____________________
Signature of Supervisee: ______________________________________________ Date: _____________________
Is the supervisee a W-2 employee?
Is the supervisor and supervisee working in the same place of employment?
If no, please provide a detailed explanation of how supervision is being conducted:
Date Supervision contract was signed:
F-60All-VS
20201201
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Verification of Supervision for Post-Graduate Mental Health Practice (Utah DRE)

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Completed 9 September 2021

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