SUPERVISION

NOTE

Clients Name:
Trainee:
Supervisor:

DOB:
Date of Service:
Date of Supervision:
AGENDA

(Since this will be an electronic form, both parties can add to it even prior to the session,
which would help set the agenda as well as allow the other person to better prepare)

_____________________________________
_____________________________________
_____________________________________


CASE REVIEW AND PLAN:

Trainee implemented plan/advice established in previous supervision session

Comments: (this section would include whether the trainee administered the agreed upon

assessment battery, or any other advice (e.g., mandated reporting); the section may also

include comments about the quality of implementation)


Reviewed scores and observations from session

Comments: (this section would include any important comments regarding scores or

qualitative observations)


Planned assessment battery for next session or Discussed case conceptualization
for feedback session/report writing

Comments: (this section may include a list of the assessments; collateral calls to other

providers; instructions for further referrals, and etc.)

TRAINEE GOALS: (this section would include feedback from the supervisor as well as the
supervisees comments regarding their needs/goals - basically, a collaborative approach to
addressing immediate training needs as well as long term professional goals)

Short-term Goals: (e.g., training on mandated reporting; practice administration of WISC-
V; learn scoring guidelines for WJ-IV)

Tools and Resources: (e.g., provide handout and link to an additional training on mandated

reporting; provide the WISC-V manual; schedule a session with the clinic assistant to practice

assessments or review scoring)

Long-term Goals: (e.g., improve case conceptualization/report writing skills)

Progress:






SUPERVISOR GOALS: (this section can include feedback from the supervisee about the
supervisor, structure of supervision or other ways in which the supervisor and the department
can meet the trainees needs; it would also include goals for self/the department identified by
the supervisor)

- _____________________________________
- _____________________________________
- _____________________________________












____________________

________________
Trainee



Signature


Date






____________________

________________
Supervisor


Signature


Date