Counseling Supervision Professional Disclosure Statement

This agreement serves to define and document the supervisory relationship between Annabelle
Frazier, Ph.D., LPC /LMHC (MS LPC #2871 / MA LMHC #10623) (“supervisor”) and _________________________ (“supervisee”), with the purpose of
 (A) Securing counseling supervision hours to satisfy requirements for licensure in ________.
 (B) Developing additional clinical competence in ______________________________.
 (C)Remediating practice deficiencies or addressing concerns around __________________ as required by the board in _____.

 In Mississippi, a back-up supervisor is required. If the supervisee requires assistance but Dr.
Frazier cannot be reached, the supervisee can reach out to the back-up supervisor in their individual supervision contract. 

 

 The supervisee has secured a secondary supervisor for onsite assistance, as required by the MS Board of Examiners. ___________________________ (“onsite supervisor”) has agreed to assist the supervisee and be present onsite when the supervisee is practicing. The onsite supervisor is licensed as LPC, license number _________________. The onsite may be contacted at ____________________________.

 

I. Context of Supervision
a. When provided for the purposes of licensure (Purpose A, above), Individual (one-on-one) supervision will occur at the rate of one [1] clock hour to forty (40) hours of services provided OR one [1] hour of supervision to twenty-five (25) hours of Direct Services. For pre-licensed clinicians working full-time, supervision typically occurs  once per week. For persons working part-time, supervision should occur no less frequently than once every other week, or  once every two
weeks. When supervision is sought for other purposes (B or C above), frequency may vary based on agreement between the supervisor and supervisee, as well as any external requirements imposed (e.g., from licensing boards, courts, or other
regulatory bodies). The supervisee must inform the supervisor of any such requirements when arranging for supervision.

 

b. Supervision involves the supervisor supporting, evaluating, and overseeing the supervisee’s work only for the purposes (A, B, and/or C above), and only within the setting listed above.

 

c. Individual supervision occurs  in-person, at ____________________________ or  via videoconferencing, using Zoom for Healthcare (with BAA). The supervisee is responsible for scheduling all supervision sessions using ________________________________ and notifying the supervisor at least 24hours in advance of any cancelation.

 

d. If supervision occurs via videoconferencing, a supervision meeting may be disrupted due to connectivity or system failure. In the event of such a disruption, the supervisee and supervisor will attempt to re-connect, will communicate about the issue by telephone, and may re-schedule the session for the next available time/day, should the connectivity issue persist, by mutual agreement. No fees will be charged for supervision sessions disrupted by system failure, within 15
minutes of the beginning of the session.

e. The supervisee and supervisor are jointly responsible for identifying an agenda for each session, including critical issues needing attention, and areas in which the supervisee needs assistance.

 

f. Dr. Frazier uses an Adlerian Integrated Developmental Model of Counselor Supervision with a focus on the developmental stage of the supervisee. Video and audio session recordings, session transcripts, and treatment documentation are used in supervision to facilitate the learning process.

 

II. Method of Supervision
a. At least once per month, the supervisee is assessed and receives informal feedback from the supervisor on skill development, documentation, ethical and legal compliance, and professional identity development, as relevant to the purpose (A, B, and/or C above) of supervision.

 

b. The supervisor provides a formal evaluation of the supervisee at least once per each three-month period of supervision (i.e., quarterly).

c. When supervision is sought for licensure or remediation purposes (purposes A or C above), the supervisor uses the formal evaluation document provided by the supervisee (as required by their jurisdiction). Formal evaluation addresses
assessment, conceptualization, interventions, administrative skills, as well as professionalism as relevant for the identified purposes of supervision.

d. When supervision is sought for skill or competence development (purpose B, above), formal evaluation consists of the supervisee’s progress towards the desired competence area.

III. Duties and Responsibilities of the Supervisor
a. Uphold the ethical guidelines of the Code of Ethics of the ACA and AMHCA, the laws of the jurisdiction(s) in which supervision occurs, and any regulations issued by the supervisor’s and the supervisee’s licensing board(s).

b. Ensure that the supervisee maintains lawful, ethical practice with attention to client welfare, dignity, and self-determination, as well as cultural competence.

c. Understand the concerns, risks, and needs presented by the supervisee’s clients in the setting and follow supervisee’s efforts to assess and treat clients.

d. Review recordings, transcripts, or documentation of supervisee’s work in the setting during supervision meetings.
e. Monitor the supervisee’s skills development for the stated purposes (A, B, and/or C above).

f. Intervene when necessary to support the supervisee’s clients as in subsections (a)-(c).
g. Be available for consultation and assistance in crisis and emergent situations.
h. Provide informal and formal assessment of the supervisee.
i. Promote the supervisee’s autonomy and skills development.
j. Review and sign off on client records, as required for the purpose identified (A, B, and/or C above).

IV. Duties and Responsibilities of the Supervisee
a. Uphold the ethical standards of the Code of Ethics of the ACA, the laws of the jurisdiction(s) in which supervision occurs, and any regulations issued by the supervisor’s and the supervisee’s licensing board(s).
b. Maintain lawful, ethical practice with attention to client welfare, dignity, and self-determination, as well as cultural competence.
c. Promptly communicate concerns around client risk, competence, crisis, and/or other supervisee and client needs as relevant. Follow the supervisor’s crisis and emergency communication plan (see part VIVI) for urgent issues.
d. Prepare and review counseling session recordings, transcripts, or documentation in advance of supervision.
e. Be prepared to discuss client cases, bringing to supervision sessions all relevant client and session materials, as well as questions and topics for discussion.
f. Complete and file case records as required by the work setting.
g. Obtain the supervisor’s signature documentation, as required for the purpose listed (A, B, and/or C above).
h. Make consistent effort to incorporate feedback and clinical recommendations from supervision into work with clients.
i. Identify personal goals for professional development and demonstrate self-awareness in assessing needs and progress towards these goals.
j. Adhere to, and promptly share with the supervisor any requirements and policiesof the supervisee’s training setting, work setting, and/or licensing board.
k. Complete assignments (e.g., readings, research, collateral contact) related to client’s cases, as assigned by the supervisor.

 

V. Confidentiality, Privacy, and Privileged Communication
a. The supervisor keeps confidential and private all information shared by the supervisee, except for disclosures required or permissible by law in the supervisor’s and/or supervisee’s practice jurisdiction.

 

b. Whenever it is practical and safe to do so, the supervisor notifies the supervisee about any disclosures the supervisor intends to make under subsection (a).

 

c. During the first session with each client, the supervisee informs the client about disclosure of information to the supervisor for the purpose of supervision (A, B and/or C above), obtains each client’s consent for this disclosure, and provides each client with the supervisor’s contact information.

d. If supervision is sought for licensure or remediation purposes (A or C above), the supervisee does not continue to see clients who decline consent for disclosure of information necessary for supervision. The supervisee informs clients of this requirement as part of informed consent and reviews this requirement whenever a client withdraws or declines to provide consent for supervisory disclosure. The supervisee promptly refers clients who do not allow supervisory disclosure of information to an independently licensed provider who does not have similar requirements.

 

e. When supervision occurs via videoconferencing, the supervisee and supervisor attend supervision sessions only in locations where client confidentiality and privilege can be maintained.

f. When the supervisee receives a court order, subpoena, or other legal request forconfidential or privileged client information (including requests initiated by the client or their legal representative) for a client whose care is supervised by the supervisor, the supervisee notifies the supervisor and obtains the supervisor’s accord before responding to the request. The supervisor responds to all such notices within 48 hours of receipt.

g. The parties’ obligations in subsections (a) and (e) will survive the termination of this agreement.

VI. The Supervisor’s Emergency Communication Plan
a. The supervisor is available to the supervisee by phone during the hours of 8 AM - 8 PM, Monday through Friday, except when arranged otherwise. The supervisee is encouraged to use text messaging to communicate the need for an urgent
check-in or supervision session.

b. If the supervisee needs emergency assistance outside of the supervisor’s availability in subsection (a), the supervisee may contact the back-up supervisor listed on page 1 of this agreement.

c. If supervision is sought for the purpose of licensure (purpose A), the supervisee does not see clients when their onsite supervisor is unavailable or absent. The supervisee may consult the on-site supervisor as needed.

VII. Payment for Supervision
a. The supervisee is responsible for paying the fees associated with supervision sessions, as outlined below (in subsection (b)). These fees are assessed for each supervision session scheduled, including sessions scheduled but not attended by the supervisee (i.e., late cancelations or no-shows). Fees may be waived solely at the supervisor’s discretion, and only when communicated to the supervisee in writing.

b. The following fees apply to all supervision sessions:
i. $150 per one [1] individual supervision session lasting 60 minutes, or
ii. $500 when four [4] individual supervision sessions (each lasting 60
minutes) are pre-paid for and scheduled in advance, or
iii. $900 when eight [8] individual supervision sessions (each lasting 60
minutes) are pre-paid for and scheduled in advance.
iv. By mutual agreement, a modified fee schedule may be arranged. If a modified fee schedule is arranged, the rate per 60-minute individual supervision session for the supervisee listed above is $___________, and the fees listed in subsections i-iii do not apply.

c. Supervision sessions scheduled but not paid for are not conducted.

d. When the supervisee cancels a pre-paid supervision session with 24-hour notice, the supervisee may reschedule at their convenience and the fee is applied to the newly scheduled session.

VIII. Terms of the Agreement
a. This agreement may be revised at any time upon the request of either the supervisor or supervisee. A formal review of this agreement can be requested at any time and revisions may be made with consent of both parties. The signatures below indicate that the parties have reviewed this agreement and received a copy.

b. This agreement may be terminated upon the request of either the supervisor or supervisee, with a 2-weeks written notice. When notice is provided, supervision sessions will continue at the cost described in VII subsection (b), and frequency (as specified in section I (a)) during the 2-week notice period.

c. Fees for supervision sessions paid for by the supervisee but not held (because they were never scheduled or were canceled with 24-hour notice) may be refunded to the supervisee upon the termination of this agreement.

 

d. As indicated by signatures below, the supervisor and supervisee acknowledge and agree to fulfil the terms, responsibilities, and duties outlined in this agreement.