Clinical Supervision Agreement

The persons entering into this contract shall strive to meet all standards set forth by the Kentucky Licensure Board for Marriage and Family Therapy and the American Association of Marriage and Family Therapy. The supervisor shall maintain her license and supervisory status with the Kentucky Board of Licensure for Marriage and Family Therapy throughout the course of the supervision contract. The supervisor shall also maintain her supervisory status with the American Association of Marriage and Family Therapy. The supervisee shall be accountable to obtain and maintain his or her associate status with the Kentucky Board of Licensure. The supervisee shall document all supervision sessions on licensure board approved forms, indicating the length of the supervision session, type of supervision, and the format of type of data presented. The supervisee shall be responsible to present the documentation to the supervisor for signing at each supervision session. The supervisee agrees to maintain requirements for professional practice including but not limited to:  Professional Liability Insurance with the terms of 1 million/3 million per occurrence and with the supervisor named as an additional insured.  Comply with regulations and standards set forth by any third party payers and state regulations  Follow through on contracts and agreements to provide care to clients  Obtain and maintain releases and permission to share confidential  client information with the supervisor. The supervisee will present clinical data to the supervisor during clinical supervision in a manner compliant with licensure regulations. The supervisee understands the licensure board requirements for case presentation in raw data form and will provide this during supervision with video of the clients. The supervisor will offer clinical supervision through individual case consultation. The supervisee may negotiate the use of shared supervision with another supervisee, group supervision, and live supervision through home visits or group therapies. The supervisor maybe contacted by phone or email at any time. Non crisis discussion of cases should be done during scheduled supervision hours. Payments are made by the supervisee to the clinical supervisor in a timely fashion. The supervisee agrees to disclose and discuss all therapeutic services provided during the course of supervision. This includes types and frequencies. The supervisee agrees to consult the supervisor in adding to the number of clients seen and the types of services provided. The supervisee agrees to make all documentation of client records available to the supervisor for clinical purposes. However, the supervisor will not be liable for the quality or care of client documentation. The supervisor and supervisee agree to be aware of and discuss dual relationships in the supervision process. The supervisee may terminate supervision with this supervisor but remain contracted with Transformations for clinical services. The supervisee may terminate contract with Transformations and remain contracted with the supervisor for supervision services provided the supervisor is in agreement with the new practice setting. This contract for clinical supervision maybe terminated by either party, for any reason, with notice. The supervisor and supervisee will notify the licensure board of any early termination of the contract. The supervisor and supervisee reserve the privilege of taking vacations or leave of absence. These may need to be reported to the licensure board and the supervisee may need a covering supervisor to be approved by the board. In accordance with informed consent, supervision is not psychotherapy, it is not a guarantee of recommendation for licensure, and it is not preparation for passing a licensing examination. This contract is subject to revision at any time upon request of either party. We agree to the best of our ability to uphold the directives specified in this supervision contract and to conduct our professional behavior according to the ethical principles of our professional associations, AAMFT.

Supervision sessions are agreed upon at the following frequency:

The fee for supervision is agreed upon at the following rate:

I understand and agree to the above contract.*

Yes

Supervisee Signature*

Name of Supervisee*

First Last

Address

Phone

Email Address

Date*

Supervisor Signature*

Name of Clinical Supervisor

First Last

License Type and License #

Address

Phone

Email Address

Date*

Clinical Supervision Contract