ࡱ> HJG bjbjoo  /  HH  }}}8$8NNN%8'8'8'8'8'8'8b:='8}N@NNR'8B  <8BBBVj R}%8BN%8BB65["}74J)67DR8086=B=87B}7NNNH :   Agreement for Supervision for Clinical Licensure This agreement is made between _____________________________________ (herein after referred to as the supervisee) and Leslie Larson, LPC (herein after referred to as the supervisor). The supervisor agrees to provide supervision in compliance with the requirements for the Licensed Professional Counselor (LPC) license in the State of Texas and in accordance with the terms below. The parties mutually agree to the following: 1. FREQENCY AND DURATION One hour of supervision shall be conducted weekly with the supervisee. Sessions will be one hour. At the outset, sessions will be held individually. At such time that more than one supervisee is under agreement with the supervisor, sessions may also be provided in a group format, alternating weekly between individual and group sessions, with at least half of the total supervision hours provided in the individual (1:1) format. Group will consist of no more than eight (8) supervisees. 2. AVAILABILITY Supervision shall occur on a set and agreed upon schedule. The supervisor may be available between scheduled sessions, as needed, for phone consultation during regular business hours (M F, 9:00 am 6:00 pm). Supervisor will be available after hours for emergent situations. 3. COMPENSATION In exchange for supervisors time, expertise and licensure, the supervisor shall be compensated $250 per month, flat fee, payable at the first supervision session per calendar month. If applicable, the first and last months payment may be prorated. 4. DURATION AND TERMINATION The period of this agreement shall be from  _____________________________________ to ______________________________, inclusive, OR  from start date ______________________________ until such time supervisee meets the hour and supervision requirements for licensure, or the agreement is otherwise terminated). This agreement may be terminated by either party upon _______ days notice. The agreement may be immediately terminated if either party does not maintain necessary qualifications or fails to follow the LPC Board Code of Ethics or Board Rules. 5. PROCESS OF SUPERVISION A. The supervisor shall Qualify as an LPC in Texas and provide this qualification to the supervisee. The supervisor shall maintain this credential for the duration of the supervision. Provide ongoing and final evaluation of the supervisees clinical skills. Provide oversight and guidance in diagnosing, conceptualizing, treating and dealing with the supervisees clients. Conduct supervision with a focus on the raw data as presented by the supervisee in supervisees clinical work. Conduct supervision as a process distinct from personal therapy or didactic instruction. Evaluate the supervisees role and conceptual understanding in the treatment process; evaluate supervisees utilization of a theoretical base and counseling principles. Conduct supervision as a personal endeavor, making a reasonable effort to ensure the supervisees competence in practice. Conduct supervision according to the LPC Code of Ethics. Provide other services as follows: __________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ The supervisee shall a) Attend supervision on the agreed upon basis. b) Apprise the supervisor of the diagnosis/case conceptualization and treatment of each client. c) Provide appropriate and current raw data and clinical materials for supervision which are Representative of the supervisees practice or of the specialty where more guidance and direction are needed Clear as to the method used Sufficient to formulate the problem Illustrative of the supervisees role, the treatment process, and the supervisees utilization of a theoretical base and counseling principles. d) Participate in supervision with a goal of increasing competency in clinical practice and keeping with the LPC Board Code of Ethics. e) Request ongoing and final evaluations of clinical skills from the supervisor. f) Come to supervision sessions prepared to discuss cases and problems in the supervisees clinical milieu, taking an active role in supervisees own clinical and professional growth. g) Participate in specific activities as follows: ___________________________________________ __________________________________________________________________________________ __________________________________________________________________________________. Both parties are encouraged to utilize the LPC Code of Ethics and Board Rules. __________________________________________ ____________________ K. Leslie Larson, MA, LPC-S date __________________________________________ ____________________ Supervisee date Receipt of ethical guidelines I have been provided a copy of the Licensed Professional Counselor Code of Ethics for the State of Texas and hereby agree to adhere to the Code while under the clinical supervision of K. 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DKfN1엓:+ۥ~`jn[Zp֖zg,tV@bW/Oټl6Ws[R?S֒7 _כ[֪7 _w]ŌShN'^Bxk_[dC]zOլ\K=.:@MgdCf/o\ycB95B24S CEL|gO'sקo>W=n#p̰ZN|ӪV:8z1f؃k;ڇcp7#z8]Y / \{t\}}spķ=ʠoRVL3N(B<|ݥuK>P.EMLhɦM .co;əmr"*0#̡=6Kր0i1;$P0!YݩjbiXJB5IgAФ޲a6{P g֢)҉-Ìq8RmcWyXg/u]6Q_Ê5H Z2PU]Ǽ"GGFbCSOD%,p 6ޚwq̲R_gJSbj9)ed(w:/ak;6jAq11_xzG~F<:ɮ>O&kNa4dht\?J&l O٠NRpwhpse)tp)af] 27n}mk]\S,+a2g^Az )˙>E G鿰L7)'PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 /_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!\theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] P.  ! /X$2$YT0Agreement for Supervision for Clinical Licensure Leslie Larson Leslie Larson8          Oh+'0 , DP t   '4Agreement for Supervision for Clinical LicensureLeslie Larson Normal.dotmLeslie Larson6Microsoft Macintosh Word@j( @87@Z7-@@)L ՜.+,0 hp|  ' $= 1Agreement for Supervision for Clinical Licensure Title  !"#$%&'()*+,-./012345689:;<=>@ABCDEFIM^LNSOPQRT]UVWXYZ[\_Root Entry F3J)K@ 1Table=WordDocument /SummaryInformation(7DocumentSummaryInformation8?MacrosG)G)VBAG)G)dir  !"#%&')*+,-./12456789:;<=>?@ABCDEFGHJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuwxyz{|0* pHdProjectQ(@= l /RJ J< rstdole>stdoleP h%^*\G{00020430-C 0046}#2.0#0#C:\WINDOWS\system32\e2.tlb#OLE Automation`ENormalENCrmaQF  * \C sB!OfficgOficg!G{2DF8D04C-5BFA-101@B-BDE5gAjAe42ggram Files\CommonMicrosoft Shared\OFFICE11\MSO.DLL#M 11 .0 Ob Library%"xMSFAs>MSFBs3@dD452EE1-E08F0A-8-02608C@4D0BB4dSadFM20L'B p&/;"1D|~ C00}t#0B# 504 B91B8E34-424B6A-922B-8B5717E5599A6DOCUME~1@\LESLIOCALS@Temp\Word8.0c8.exdd=".E .`(M A"7ThisDocumentGT isDlcuen 2` Hj1By",Q""+K*y *\CNormalrU~~~~~~~~h K*.iM;&#n  e __SRP_0 __SRP_1$__SRP_2 (__SRP_30 ޻1i/E5c n- ThisDocumentProjectF /C:\PROGRA~1\COMMON~1\MICROS~1\VBA\VBA6\VBE6.DLLVBA  !` F5C:\Program Files\Microsoft Office\OFFICE11\MSWORD.OLBWord p0FC:\WINDOWS\system32\stdole2.tlbstdole )qL-[DR?C:\Program Files\Common Files\Microsoft Shared\OFFICE11\MSO.DLLOffice  .E .`M C:\WINDOWS\System32\FM20.DLLMSForms )q4 DBjK+WY6C:\DOCUME~1\LESLIE~1\LOCALS~1\Temp\Word8.0\MSForms.exd  qk FހH돣M[hwFRA{!k@5'BҋB ` CheckBox1@ҋB ` FDocument CheckBox2CҋB ` P4@4@erU~~~y     CheckBox1 q( CheckBox2`rU 0)Q  8ya< 1 DyaQ[Ey14 @ 2rU P @4 @@nJ.\/U7LހH돣M[hwFRA{!k@5'x"CheckBox1, 0, 0, MSForms, CheckBox"CheckBox2, 1, 1, MSForms, CheckBoxk@5'ހH돣M[hMEThisDocument 3_VBA_PROJECTI+ PROJECTvPROJECTlk}PS"SS"s6"<<<(1Normal.ThisDocument (% %*40@ %%%*!@`@88hP/RJ*\R8005*#67$*\Rffff*0;4a5208aa88<Dx̰Attribute VB_Name = "ThisDocument" Bas1Normal.VGlobal!SpaclFalse CreatablPre declaIdTru BExposeTemplateDeriv$Custom izC1ControlCheckBox1, 0MSFs, Dž 2, ay  *\G{000204EF-0000-0000-C000-000000000046}#4.0#9#C:\PROGRA~1\COMMON~1\MICROS~1\VBA\VBA6\VBE6.DLL#Visual Basic For Applications*\G{00020905-0000-0000-C000-000000000046}#8.3#0#C:\Program Files\Microsoft Office\OFFICE11\MSWORD.OLB#Microsoft Word 11.0 Object Library*\G{00020430-0000-0000-C000-000000000046}#2.0#0#C:\WINDOWS\system32\stdole2.tlb#OLE Automation*\CNormal*\CNormalsB(*\G{2DF8D04C-5BFA-101B-BDE5-00AA0044DE52}#2.3#0#C:\Program Files\Common Files\Microsoft Shared\OFFICE11\MSO.DLL#Microsoft Office 11.0 Object Library*\G{0D452EE1-E08F-101A-852E-02608C4D0BB4}#2.0#0#C:\WINDOWS\System32\FM20.DLL#Microsoft Forms 2.0 Object Library*\G{091B8E34-4244-4B6A-922B-8B5717E5599A}#2.0#0#C:\DOCUME~1\LESLIE~1\LOCALS~1\Temp\Word8.0\MSForms.exd#Microsoft Forms 2.0 Object Library.E .`M  /RJ7ThisDocument0;4a5208aaThisDocument <"V AQZ@`@&WordkVBAWin16~Win32MacVBA6#Project1 stdole`Project- ThisDocument< _EvaluateNormalOfficeuMSFormsC CheckBox1Documentj CheckBox2`  ID="{EAE22447-9A98-43CB-8CCD-1E889DCFA7E4}" Document=ThisDocument/&H00000000 Name="Project" HelpContextID="0" VersionCompatible32="393222000" CMG="757745D2CF43D343D343D343D3" DPB="EAE8DA6D4E6E4E6E4E" GC="5F5D6FF8911807190719F8" [Host Extender Info] &H00000001={3832D640-CF90-11CF-8E43-00A0C911005A};VBE;&H00000000 &H00000002={000209F2-0000-0000-C000-000000000046};Word8.0;&H00000000 @ҋB `ThisDocumentThisDocument F Microsoft Word 97-2004 DocumentPROJECTwm~)CompObj`NB6WWord.Document.8