I acknowledge I will be receiving services from a clinician who:
1) holds a Master's degree in counseling (or equivalent).
2) is working toward unrestricted licensure and, therefore,
3) whose work is supervised by a Licensed Clinical Psychologist.
By signing this form, I acknowledge that I am in agreement to receiving services from this supervised clinician and that my personal health information will be reviewed by a Licensed Clinical Psychologist for supervision purposes.