Supervision Form - Masters Level

Acknowledgement of Services Requiring Supervision
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.
Name of Patient (if different)

First Name Last Name
Name *

First Name Last Name
Date *

Month Day Year
Date
Signature of Patient, Parent, or Legal Guardian *

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