ࡱ> ] bjbjgg . &b &b4}x ^^^rrr8fTry\ (> > > "#$OxQxQxQxQxQxQx$X|ux^&%!""&%&%ux> > y)))&%|8> ^> Ox)&%Ox))Jn\Fu> M!s%6/qB;xy0yqq2&~u^u&%&%)&%&%&%&%&%uxuxV(~&%&%&%y&%&%&%&%&%&%&%&%&%&%&%&%&% B :  CLINICAL SOCIAL WORK SUPERVISION CONTRACT Kentucky Board of Social Work, 125 Holmes Street, Suite 310, Frankfort, KY 40601 502-564-2350 / bsw.ky.gov FOR OFFICE USE ONLY: Reviewed by: ______ Approved by: ______ KRS 335.080(3) allows a certified social worker (CSW) to engage in the practice of clinical social work under the supervision of an approved licensed clinical social worker (LCSW) supervisor as directed by the board and set forth 201 KAR 23:070. The CSW/supervisee shall remain under supervision until independently licensed as a LCSW or until the contract is terminated in writing to the board. A new contract is required if: 1) the clinical workplace setting or 2) the supervisor of record changes. Any job changes or supervisor changes shall be reported to the board; otherwise it could result in additional time spent in supervision. This contract shall be reviewed and approved or disapproved within ninety (90) days of its submission. THE CSW MAY NOT BEGIN CLINICAL SOCIAL WORK PRACTICE UNTIL THIS CONTRACT HAS BEEN APPROVED BY THE BOARD. DEFINITIONS: 201 KAR 23:070, Section 1 (1) "Practice of clinical social work" means the practice of social work that focuses on the evaluation, diagnosis, and treatment of an emotional disorder and mental illness as related to the total health of the individual and that meets the requirements of Section 3 of this administrative regulation. (2) "Supervision" means the educational process of utilizing a partnership between a supervisor and a supervisee aimed at enhancing the professional development of the supervisee in providing clinical social work services. (3) "Supervisor of record" means the supervisor who assumes responsibility for the practice of a certified social worker pursuant to KRS 335.080(3) and 335.100(3). ANSWER ALL QUESTIONS IF ANSWER IS NO OR NONE, PLEASE INDICATE; IF NON-APPLICABLE, INDICATE N/A. SECTION I. INFORMATION ABOUT THE CSW/SUPERVISEE FULL NAME:  FORMTEXT       CSW LICENSE #  FORMTEXT       ISSUE DATE:  FORMTEXT       HOME ADDRESS:  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Street City State Zip PREFERRED EMAIL ADDRESS:  FORMTEXT       BEST DAYTIME TELEPHONE NUMBER:  FORMTEXT       SECTION II. PLEASE CHECK THE CATEGORY OF APPROVAL YOU ARE SEEKING:  FORMCHECKBOX  Preapproved evaluation. An applicant shall submit a contract for the supervised experience which will be taking place over the required time period and shall have the contract approved by the board.  FORMCHECKBOX  Transitional evaluation. An applicant who has accumulated an amount less than the full amount of qualifying experience while licensed in another state or while working in a clinical social work setting that does not meet the broad exposure requirement under 201 KAR 23:070, Section 7(3) shall submit his or her application along with appropriate documentation of supervision completed to the date of his or her application. An applicant shall also submit with his or her application a contract under paragraph (c) of this subsection for the remainder of the supervised experience.  FORMCHECKBOX  Clinical practice contract. A certified social worker who desires to practice clinical social work but is employed less than 20 hours per week, which amount of part-time work does not qualify as supervised experience as established by KRS 335.100(1) (b), shall submit a contract. THIS CONTRACT DOES NOT ALLOW HOURS TO COUNT TOWARDS LICENSURE AS A LICENSED CLINCIAL SOCIAL WORKER. SECTION III. EMPLOYMENT / CLINICAL SOCIAL WORK SETTING: Name of Employer/ Facility:  FORMTEXT       Phone:  FORMTEXT       Facility Address:  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Street Address City State Zip Code SECTION IV. JOB DESCRIPTION ATTACH a copy of the CSW s OFFICIAL JOB DESCRIPTION ON OFFICE LETTERHEAD, signed by HR or agency director. SECTION V. SUPERVISOR OF RECORD Name:  FORMTEXT       KY LCSW license #  FORMTEXT       Original Issue Date:  FORMTEXT       Address:  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Street City State Zip Email Address:  FORMTEXT       Telephone: Home:  FORMTEXT       Office:  FORMTEXT       What is the date of the supervisor of record s most current LCSW Supervision training (required every renewal period)?  FORMTEXT       ATTACH a copy of your most current LCSW Supervision course certificate of attendance. SECTION VI. ADDITIONAL SUPERVISOR(S) (If you will be receiving supervision from any other supervisor, please list each one) Name:  FORMTEXT       KY LCSW license #  FORMTEXT       Original Issue Date:  FORMTEXT       Address:  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Street City State Zip Email Address:  FORMTEXT       Telephone: Home:  FORMTEXT       Office:  FORMTEXT       What is the date of the additional supervisor s most current LCSW Supervision training (required every renewal period)?  FORMTEXT       ATTACH a copy of your most current LCSW Supervision course certificate of attendance. ADDITIONAL SUPERVISOR(S) Name:  FORMTEXT       KY LCSW license #  FORMTEXT       Original Issue Date:  FORMTEXT       Address:  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Street City State Zip Email Address:  FORMTEXT       Telephone: Home:  FORMTEXT       Office:  FORMTEXT       What is the date of the additional supervisor s most current LCSW Supervision training (required every renewal period)?  FORMTEXT       ATTACH a copy of your most current LCSW Supervision course certificate of attendance. ADDITIONAL SUPERVISOR(S) Name:  FORMTEXT       KY LCSW license #  FORMTEXT       Original Issue Date:  FORMTEXT       Address:  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Street City State Zip Email Address:  FORMTEXT       Telephone: Home:  FORMTEXT       Office:  FORMTEXT       What is the date of the additional supervisor s most current LCSW Supervision training (required every renewal period)?  FORMTEXT       ATTACH a copy of your most current LCSW Supervision course certificate of attendance. SECTION VII. PLAN OF CLINICAL SOCIAL WORK ACTIVITIES: 201 KAR 23:070, Section 5 (5). Describe the nature of this clinical practice:  FORMTEXT       What age and type of clients will be treated by the CSW/supervisee?  FORMTEXT       What therapies and treatment modalities will be used?  FORMTEXT       What is the estimated length and duration of therapy?  FORMTEXT       Will the CSW/supervisee be performing client assessments/evaluations?  FORMTEXT       If not, explain: Will the CSW/supervisee be diagnosing mental illness or emotional disorders?  FORMTEXT       If not, explain: Describe the type of therapy will the CSW/supervisee be providing?  FORMTEXT       B. Frequency, duration and nature of the clinical supervision. 201 KAR 23:070, Section 5 (6). We agree that the frequency of individual supervision shall not be less than two (2) hours during every two (2) weeks of clinical social work practice until this contract is terminated or the CSW is licensed as an independent LCSW; We agree that the CSW/supervisee shall obtain no less than 100 hours of the required supervision by individual supervision; and We agree that group supervision will not be permitted in groups of more than six (6) supervisees. Please describe what will be done in supervisory sessions; and how will they be conducted:  FORMTEXT       C. Conditions or procedures for termination of the supervision 201 KAR 23:070, Section 5 (7). Please describe the conditions or procedures for termination of the supervision contract:  FORMTEXT       D. CSW/supervisee s direct contact with clients. 201 KAR 23:070, Section 7. 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/CJOJQJ^JhC;hvCJOJQJ^JhvCJOJQJ^JhMh}\CJOJQJ^JhMh9CJOJQJ^JhMhq KCJOJQJ^Jh5CJOJQJ^JhMhq K5CJOJQJ^Jhv5CJOJQJ^JhvhvCJOJQJ^J<<<<<<<<<<<======+=,=-=7=óym^my^O^<^%jhMh%?CJOJQJU^JhMhT^CJOJQJ^JhMh%?CJOJQJ^JhwCJOJQJ^JhMhjCJOJQJ^JhCJOJQJ^JhhtX6CJOJQJ^Jhh /5CJOJQJ^Jhh95CJOJQJ^Jhh{?CJOJQJ^JhhcCJOJQJ^Jhhc5CJOJQJ^JhhxCJOJQJ^J7=8=> *ƚȚʚԚ֚Ի֬s`Q;``s+j!hMh%?CJOJQJU^JhjHh%?CJOJQJ^J%jhjHh%?CJOJQJU^JhjHhT^CJOJQJ^JhjHhjCJOJQJ^JhwCJOJQJ^JhMhjCJOJQJ^JhMh%?CJOJQJ^J0jhMh%?CJOJQJU^JmHnHuU%jhMh%?CJOJQJU^J+j hMh%?CJOJQJU^J      hours per week (minimum of 30 hours counts as a full-time job); or Part-time at  FORMTEXT       hours per week (minimum pf 20 hours counts as a part-time job). HOW MANY *HOURS* PER WORK WEEK WILL THE CSW/SUPERVISEE SPEND IN DIRECT CLIENT PROFESSIONAL-RELATIONSHIP? (Note: minimum is sixty (60) percent of employment hours per week)  FORMTEXT       SECTION VIII. SIGNATURES AND AFFIRMATIONS SUPERVISOR OF RECORD: I agree to serve as the supervisor of record for the above named CSW/supervisee, who is a candidate for licensure as a licensed clinical social worker and I affirm that: I have discussed this contract with the CSW/supervisee and accept responsibility for its implementation; I shall be held accountable to the board for the services given to this CSW/supervisee s clients; The CSW/supervisee is an employee of the facility listed in the clinical practice setting, has no direct or indirect financial interest other than employment, and Social Security and income tax are deducted from the CSW s salary; When the CSW/supervisee completes the activities for clinical social work experience and applies for licensure as a LCSW or terminates this contract, I will promptly and accurately document the hours under supervision, and comment on the CSW/supervisee s ethical behavior, therapeutic competency, and ability to practice independently; I will immediately notify the board in writing if the conditions of this contract are changed or this contract is terminated; As an approved supervisor of record, I certify that I meet the criteria in 201 KAR 23:070, Section 4 , and I: do not have an unresolved citation filed against me by the board; do not have a suspended or probated license; do not have a previous or existing personal relationship with the CSW/supervisee. have been in the practice of clinical social work for three (3) years following licensure in Kentucky or another jurisdiction as an independent licensed clinical social worker; and have completed a board-approved three (3) hour training course on supervisory practices and methods for licensed clinical social workers. (7) A supervisor and supervisee may agree to use electronic supervision. Supervisor of Record _______ Date (SIGN HERE) CSW/SUPERVISEE: I, the CSW/supervisee, have read and agree to comply with the provisions of this contract and further state as follows: I shall remain under supervision as long as I am practicing clinical social work as a CSW; I state that I am an employee of the facility listed in the clinical practice setting and have no direct or indirect financial interest other than my employment; and I state that I am an employee and have Social Security and income tax deducted from my salary as required by 201 KAR 23:070 Section 5 (8) (b). CSW/Supervisee _____________________________________________________ Date (SIGN HERE) AGENCY SUPERVISOR  Sign this section If the supervisor of record is not the CSW s agency/employment supervisor. I am the agency supervisor for the CSW/supervisee; I have reviewed the proposed contract and affirm the agency will support the proposed practice experience as described in Sections A-D of the Plan of Clinical Social Work Activities; and The CSW/supervisee is an employee of the facility listed in the clinical practice setting and has no direct or indirect financial interest other than my employment, and Social Security and income tax are deducted from the CSW s salary. Agency Supervisor ________ Date (SIGN HERE) COMPLETE THE SECTION BELOW ONLY IF THE CSW AND SUPERVISOR OF RECORD ARE NOT EMPLOYED BY THE SAME AGENCY/EMPLOYER SECTION IX. SHARED RESPONSIBILITY FOR SUPERVISION RECEIVED OUTSIDE OF EMPLOYMENT SETTING SHARED RESPONSIBILITY FOR QUALITY OF SERVICES: We, the undersigned, acknowledge that we mutually share professional responsibility for the clinical social work services provided to clients by the CSW/Supervisee and are jointly accountable for the quality of the services provided. CONFIDENTIALITY OF RECORDS: We further acknowledge that since the supervision will take place outside the agency of employment and that agency cases will be used in this supervisory relationship, confidentiality of patient records shall be maintained by all parties. Supervisor of Record: _______________________________________ License No.:  FORMTEXT       Date: ___________ (SIGN HERE) CSW/Supervisee: ___________________________________________ License No.:  FORMTEXT       Date: ____________ (SIGN HERE) Agency/Employer Representative: Name:  FORMTEXT       ________________________________________________________ Date: ____________ (SIGN HERE)     PAGE 1 04/2016  PAGE \* MERGEFORMAT 4 Date reviewed: ___________ Approved: ________________ Incomplete: ___________ Reason(s) incomplete / comments: TVXZhjlvxz(,`d~ƹƹƹƹxl]l]l]Q>%jhhCJOJQJU^JhCJOJQJ^JhhwCJOJQJ^JhwCJOJQJ^Jhzhw5CJOJQJ^Jhzh%5CJOJQJ^Jh S5>*CJOJQJ^J"hzhz5>*CJOJQJ^Jh S5CJOJQJ^Jhzh5CJOJQJ^JhjHCJOJQJ^JhjHhT^CJOJQJ^JhjHhwCJOJQJ^JΜМҜܜޜ68`ȯȣp^L=+"hMh 5>*CJOJQJ^JhMh<_CJOJQJ^J"hMh|P5>*CJOJQJ^J"hMhc5>*CJOJQJ^J"hMh<_5>*CJOJQJ^J"hMhSZ5>*CJOJQJ^Jh5>*CJOJQJ^Jh /CJOJQJ^J0jhMhCJOJQJU^JmHnHu%jhhCJOJQJU^J+j!hMhCJOJQJU^JhhCJOJQJ^J `fh̞*`ȟ (<TŶѪћ}nn_O_hMhmg5CJOJQJ^JhMhmgCJOJQJ^Jh qdh1CJOJQJ^Jh qdh|PCJOJQJ^Jh qdhZ\CJOJQJ^Jh qdh9CJOJQJ^JhCJOJQJ^JhMhCJOJQJ^Jh1CJOJQJ^JhMh1CJOJQJ^JhMh9CJOJQJ^JhMh<_5CJOJQJ^JT x<>@ʬ̬Ю & Fgdgd hG$^hgdy0G$gdjH & FG$gdW2{ & FgdW2{ & Fgdj: & Fgd "lHPrtԣ֣ܣޣ&~$bz³zk\\P\Ph1CJOJQJ^JhMhZ CJOJQJ^JhMhZ\CJOJQJ^JhBCJOJQJ^JhMh<_CJOJQJ^JhMhFdCJOJQJ^JhMh9CJOJQJ^JhMh1CJOJQJ^JhMh+pCJOJQJ^Jhj:hBCJOJQJ^JhMhmgCJOJQJ^Jhhmg5CJOJQJ^J¥ڥ (Dvz<NP`bnp4֪:<>@j坎schMh15CJOJQJ^Jhwhj:CJOJQJ^Jhy0CJOJQJ^JhMhW2{CJOJQJ^JhwhW2{CJOJQJ^Jhj:hW2{CJOJQJ^Jhq,hW2{CJOJQJ^Jh8KhW2{CJOJQJ^JhjHCJOJQJ^JhW2{CJOJQJ^JhQPhW2{CJOJQJ^J&jvԫګ$دtdUIUdUIU=hvCJOJQJ^JhCJOJQJ^JhMhCJOJQJ^JhMh5CJOJQJ^J"hMh5>*CJOJQJ^Jh* CJOJQJ^JhMhO'lCJOJQJ^JhMh9CJOJQJ^JhMh95CJOJQJ^JhMh|PCJOJQJ^JhMh|P>*CJOJQJ^JhMh >*CJOJQJ^JhMh9>*CJOJQJ^JدگҰְذptLNprАueuVF7hMh#BCJOJQJ^JhMh#B5CJOJQJ^JhhCJOJQJ^Jhvh5CJOJQJ^JhvhCJOJQJ^JhvCJOJQJ^J"hMh5>*CJOJQJ^JhCJOJQJ^J"hMh56CJOJQJ^JhMh>*CJOJQJ^JhMh5CJOJQJ^JhMhCJOJQJ^Jhvhv5CJOJQJ^JrtLN$&d P a$gdP.gd* $&d P a$gd* $&d P a$gd#B &d P gd|H<gd#B^gdv & Fgdv^gd & Fgdgdr~ ¶ ﾲygXgXgM?hMhSZ>*OJQJ^JhP.>*OJQJ^JhP.5CJOJQJ^JaJ#hP.hP.5CJOJQJ^JaJhMhCI>*OJQJ^J"h* h* 56OJQJ^JaJh#B5OJQJ^JaJh#BCJOJQJ^Jh|H<CJOJQJ^JhMh#BCJOJQJ^JhMh#B5CJOJQJ^J"hMh#B5>*CJOJQJ^JhMh#B>*CJOJQJ^J6.^`np p^p`gdP.gdvgdsFgdy0gdO'lgdP.$a$gd $&d P a$gdP.  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