1. Modelos
  2. Clinical Supervision Contract Template

Clinical Supervision Contract Template

Utilizado 4,872 vezes

Our clinical supervision contract template is customizable and available for free, delivering the perfect baseline to start creating your supervision outlines and rules.

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  1. Modelos
  2. Clinical Supervision Contract Template

Clinical Supervision Contract Template

Image 1

Created by:



Prepared for:



Company Property: (Property.Name)

Company Address: [Supervisee.StreetAddress][Supervisee.City][Supervisee.State][Supervisee.PostalCode]

Purpose of Agreement

By signing this agreement, [Supervisor.FirstName][Supervisor.LastName] (“Supervisor”) and [Supervisee.FirstName][Supervisee.LastName] (“Supervisee”) enter into a clinical supervision experience together. The Supervisor and Supervisee, collectively referred to as Parties, have discussed the necessary issues to provide the context for this supervision.

This agreement will begin on (Effective.Date) (“Effective Date”) and continue until (End.Date) (“End Date”) or until both Parties consent to the termination in writing.

Terms of Supervision

The Supervisor agrees to commit (Number) hours per day/week/month to individual, group, or dyadic supervision of the Supervisee. These hours will be used to oversee staff clinical cases, review therapeutic interventions and orientations, and discuss counter-transference and other matters that advance the professional and clinical understanding and development of the Supervisee.

A Party unable to attend one of the scheduled supervisory meetings must give advance notice of (Number) hours. In the event of illness, either Supervisor or Supervisee will make every attempt to notify and reschedule the meeting as soon as possible.

Supervisor Information

The Supervisor agrees that the below information is truthful:

Supervisor Information

Full Name:



Supervisory Credentials:

License Number:

License Issue Date:

License Expiry Date:

Licensure State:

Contact Number:


Contact Email:


Consent and Confidentiality

Clients must be informed, and the Supervisee must obtain verbal consent if they are part of a supervisory meeting. The Supervisee must provide the clients with the information and credentials of the Supervisor. Further, both Parties will handle the client information with care and confidentiality, following HIPAA laws, local clinical regulations, and ethics specific to the license of the Supervisor.

Both Parties agree to not disclose this agreement to any other Party without the written consent of the other Party. While both Parties can disclose the supervisory relationship between them, the Supervisor and Supervisee must make every effort to protect the privacy and confidentiality of the other.

Liability Insurance

The Supervisor and Supervisee both maintain professional liability insurance. However, the Supervisee will provide insurance coverage documentation to the Supervisor before the Effective Date.

Supervisee Emergencies

The Supervisee/Supervisor will call 911 and/or the (State) Crisis Emergency Line should a client be in imminent danger of a threat, suicide, or homicide. Should either Party learn of child/adult/elder/dependent abuse, they must contact the (State) reporting line within 24 hours.

Further, should both Parties not be present during the client emergency, the Supervisee must contact and inform the Supervisor, preferably within (Number) hours. The Supervisee must also inform any appropriate individual at their employment agency.

Should the Supervisee be unable to contact the Supervisor, they must contact the next agreed-upon person, listed below as Emergency Contact:

Primary Emergency Contact Name:


Primary Emergency Contact Number:


Secondary Emergency Contact Name:


Secondary Emergency Contact Number:


Use of Technology-Assisted Services

This agreement might have remote sessions as part of the required monthly hours. In the case of remote sessions, Parties will use (Software) to conduct the meetings. This (Software) uses end-to-end encryption to protect data and is HIPAA-compliant.

Any online sessions must be conducted from a private and protected device using a private network to ensure confidentiality. If there are reconnection issues, both Parties will try to reconnect after (Number) minutes or contact the other to reschedule the meeting if the problem persists.

The Supervisee must note the following policy regarding the use of technology for supervisory meetings:

  • No client information will be disclosed over text or any other mobile messaging system. Mobiles are only used to arrange meetings or similar housekeeping issues.

  • No client information must be disclosed over the phone, as it’s not confidential.

  • The Supervisor prefers to be contacted by email/phone to arrange and modify sessions and relay housekeeping issues. Housekeeping issues are signing supervisory forms, sharing resources and interventions, and more. No client or otherwise confidential information must be shared by email.

Structure of Supervision

The supervision style stems from (Supervision.Style). The supervision style implements steps from approaches like (Approach.One), (Approach.Two), (Approach.Three), and (Approach.Four). The focus of these clinical sessions will be professional development and ethical conduct.

The atmosphere of supervision sessions should allow mutual respect and open communication without fear of negative consequences. As such, disagreements or dissonance will be handled through mutual discussion. The Supervisee understands that they have to be able to discuss their clinical development, any issues with it, and pertinent cases of each supervision.

The Supervisor agrees not to knowingly delve into any personal issue of the Supervisee in these discussions. The Supervisee should inform the Supervisor of any personal boundaries they cross but be open to personal therapy to address any issues which inhibit the ability of the Supervisee to be objective with clients.

The Supervisor will sign off on all hours the Supervisee conducts with them. Further, the Supervisor acknowledges that they will fill in any required forms, including but not limited to approval forms from the state and credentialing bodies.

Identification Goals

Both Parties have identified the following goals they hope to achieve through this agreement:

(Enter value)

Full Agreement

The laws of (State) govern this agreement. By the Parties adding their signatures below, both Supervisor and Supervisee agree to uphold the terms of this agreement. Both Parties further consent to abide by the ethical codes of the applicable license, governing board, or credentialing body.







Clinical Supervision Contract Template

Utilizado 4,872 vezes

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