Agency Letterhead

Clinical Supervision Record

Supervisee:
Supervisor:
Date:
Check all Topics Discussed:
Duties & Comprehensive skills Cases & Assessment Information &
expectations evaluation referral

Professionalism Process recording High Risk issues Evaluation issues

Judgment Decision making Progress notes Termination
Communication Problem solving Goals & objectives Diversity issues
skills
School topics & Initiative Treatment planning Mezzo practice
deadlines issues
Attitude Flexibility Crisis intervention Macro practice issues
Time management Self-awareness Practice/intervention Ethical issues
skills
Learning plan Accountability Specific EBP Other:
techniques
Comments:

Supervisee Strengths:

Challenges:

Tasks to be completed by the next supervision session or date specified:

Supervisee Signature: ________________________________

Supervisor Signature: ________________________________

Adapted from SDSU, Kim Archuletta, LCSW