Date Approved_________

 

LOUISIANA

LICENSED PROFESSIONAL COUNSELORS 

BOARD OF EXAMINERS

 

MFT INTERN REGISTRATION OF SUPERVISION SECTION 3: SUPERVISION AND SUPERVISED CLINICAL EXPERIENCE PLAN

 

INSTRUCTIONS:

 

This form is to register your board approved LMFT supervision with the LPC Board. You must submit SECTION 1 of this form to and paid the fee of $100.00 before submitting SECTION 2 and SECTION 3. All three sections may be submitted at one time or separately. A copy of your statement of Practice (guidelines and sample available on website) must be included with this form.

 

Mail to: LPC Board of Examiners, 8631 Summa Avenue, Baton Rouge, LA 70809

Phone 225/765-2515 C FAX 225/765-2514

Email lpcboard@eatel.net C Website www.lpcboard.org

 

A.  SUPERVISOR DATA

 

MFT Intern Applicant Name __________________________________________

 

Current Address _____________________________________________________

 

City, State, Zip _______________________________________________________

 

Home Telephone _______________________ Telephone Work _________________

 

Email ________________________________________

 

 

Name of Supervisor______________________________________________________

 

Current Address _________________________________________________________

 

City/State/Zip ____________________________________________________________

 

Telephone Home ___________________ Telephone Work _________________________

 

Email ______________________

 

Is supervisor a relative of the applicant?  ____ Yes ____ No

 

If yes, state relationship__________________________________________________________

 

 

B.  MFT INTERN SUPERVISED EXPERIENCE PLAN

 

Name of Marriage and Family Therapy Intern

 

______________________________________________________________________________

 

Name of Supervisor _____________________________________________________________

 

Instructions

The supervised experience plan is a written agreement on a form required by the Advisory Committee that establishes the supervisory framework for the MFT Intern's postgraduate clinical experience and describes the expectations and responsibilities of the supervisor and supervisee.

 

The supervisor and supervisee need to discuss their expectations and fill out the required form. Please add more pages as needed using the same format.

 

******************************************************************************

 

Supervision will begin _________________________________________________________

(Month, Day, Year)

 

Expected conclusion of supervision _______________________________________________

(Month, Year)

 

Location where supervision will be conducted (please check all applicable locations)

 

In the supervisor's office  _____

 

In the intern's practice setting  _____

 

Other, specify  ____________________________________

 

Frequency of face-to-face supervision

 

Weekly ___...Every other week ___...Other, specify ____________

 

How long the usual supervision session will be _______________

 

Please check types of face-to-face supervision that will be included:

 

Co-therapy Supervision (Supervision outside the session on cases in which the supervisor is a co-therapist) _____

 

If yes, expected frequency ____________________

 

Group Supervision (Supervision with more than 2 and no more than 6 interns regardless of the # of supervisors) _____

 

If yes, expected frequency ____________________

 

Individual Supervision (Supervision of 1 or 2 individuals

by 1 supervisor) _____

 

If yes, expected frequency ____________________

 

Please check how information about therapy provided will be shared with the supervisor and estimated percentages of time each will be used.

 

 

Audiotapes                 ____ yes  ____ no  _____ % of time will be used

 

Videotapes                 ____ yes  ____ no  _____ % of time will be used

 

Live Supervision        ____ yes  ____ no  _____ % of time will be used

 

Note 2: Supervision must be based on direct observation, videotape, or audiotape of the MFT intern's work. Case notes alone are not sufficient.

 

Please check yes or no for the next section.

 

We have discussed:

Content Area of Supervision	Yes	No
1. The roles and responsibilities that we each have in this supervisory relationship
2. The supervisor's supervision style
3. Our agreed upon theoretical orientation for the supervision
4. How we will handle confidentiality regarding the supervision
5. The confidentiality issues and coordination involved in working with any other clinical and administrative supervisors who might be involved in the practice setting
6. Any issues, rules, regulations specific to the agency/institution in which the therapy and/or supervision will be conducted such as rules about videotaping, removing case notes from the premises, etc.
7. How we will provide feedback to one another
8. How we will establish learning objectives and how we will decide when these learning objectives need to be changed
9. Evaluation procedures C when formal evaluation discussions will take place, how they will be documented, what will be used for the evaluation criteria
10. How we will handle stumbling blocks/disagreements/etc. and how we will handle the situation if either of us wishes to terminate this agreement
11. Reporting requirements and emergency procedures for high risk or abusive clients
12. The procedure the intern will use in case of emergencies, including the first steps the intern needs to take, how the supervisee can reach the supervisor, mandated reporting, etc.
13. The required ethical codesCsupervisor's and intern's responsibility, what codes besides the Code of Ethics for Licensed Marriage and Family Therapists in Louisiana the intern must abide by, what to do if these ethical codes differ
14. Record keepingChow records of supervision will be kept, both session notes and the log of supervision
15. Use of the Statement of Practice