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Individual Supervision Records
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Supervisor:
Date / Start Time
Date
Time
Supervisee:
Total time
Input your supervisee total time here
Direct time
Input your supervisee direct time here
Models of Supervision Used (Check All That Apply):
Reflective Practice
Developmental
Competency Based
Directive
Others
Single Line Text
Topics Discussed (Check All That Apply):
Duties & Expectations
Professionalism
Judgment
Communication Skills
School Topic Issues
Attitude
Professional Development
Assessment / Evaluations
Decision making
Problem Solving
Concerns
Flexibility
Self-awareness / self-care
Accountability
Cases Updates
Safety / High Risk Issues
Progress Notes
Goals & Objectives
Treatment Planning
Crisis Intervention
Practice/Intervention Skills
Information & Referrals
Case Management
Therapeutic Rapport issues
Termination
Diversity/Culture
Continuity / level of Care
Ethical issues
Counter Transference Issues
Court related issues
Other (Specify):
Single Line Text
Others (Please specify here)
Checkboxes
EPBs (Specify):
Single Line Text (copy)
EPBs (Please specify here)
Methods Used (Check All That Apply):
Role Play
Readings / Didactic
Audio/Video Recordings
In person Supervision
Clinician Report
Case Presentation
Electronic
audio
video
Comments: (Ex. Supervisee strengths, challenges, task(s) that need completion, next session focus)
Supervisor Signature
Submit
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