Supervisory Plan Template

Guidelines on Filling in Supervisory Plan

Filling out the Supervisory Plan form is a critical step for associate clinical social workers, professional clinical counselor interns, and their supervisors in California. This document lays the groundwork for the supervisory relationship and outlines the goals, objectives, and responsibilities of each party involved. It serves as an official record that ensures both the supervisor and the supervisee understand their commitments and duties. A well-prepared plan not only complies with regulations but also contributes to the professional development of the supervisee. Below are the steps needed to accurately complete the form.

1. Registrant Information: Start by providing the full legal name of the registrant (associate clinical social worker or professional clinical counselor intern) by typing or clearly printing in ink. Include the last, first, and middle names.
2. Registration Number: Enter the registration number assigned to the registrant by the Board.
3. Registrant Address and Telephone: Fill in the registrant's current address, including the number and street, city, state, and zip code. Include both business and residence telephone numbers.
4. Licensed Supervisor Information: Input the supervisor's full name (last, first, middle), their license number, and the expiration date of their license.
5. Employer Details: Provide the name of the supervisor's employer, as well as the employer's telephone number and address (number and street, city, state, zip code).
6. Employment Setting: Indicate the employment setting by selecting the appropriate category from the list provided (e.g., Private Practice, Licensed Health Facility, Governmental Entity, etc.).
7. Goals and Objectives: Briefly describe the goals and objectives of the supervisory relationship. This should outline what the supervisee aims to achieve under this supervision.
8. Certification and Signatures: Both the supervisor and the registrant must certify their understanding of the responsibilities involved in clinical supervision. Each party must sign and date the form, declaring the information provided is true and correct under penalty of perjury under the laws of the State of California.

Once completed, the original signed form must be submitted to the Board upon the registrant's application for examination eligibility. This submission is crucial for moving forward in the licensure process. A carefully filled-out supervisory plan ensures that the supervisory relationship is built on a solid foundation of mutual understanding and professional standards.

What is a Supervisory Plan, and why is it required?

A Supervisory Plan is a document that outlines the structured approach for supervision between a licensed mental health professional and an individual working towards licensure as a Clinical Social Worker or Professional Clinical Counselor in the state of California. It's a requirement under Title 16, California Code of Regulations (CCR) Sections 1870.1 and 1822, as well as Business and Professions Code Section 4996.23(a) and 4999.12(h). This plan is needed to ensure that the supervision provided meets the state’s standards, aiming for the professional development and ethical practice of the supervisee. It's a crucial step towards examination eligibility and further assures that both parties understand their responsibilities and the goals and objectives of the supervision period.

Who needs to complete and sign the Supervisory Plan?

Both the registrant (associate clinical social worker or professional clinical counselor intern) and the licensed mental health professional providing supervision are required to complete and sign the Supervisory Plan. The licensed supervisor must be acceptable to the Board as defined in the relevant sections of the Business and Professions Code and the California Code of Regulations. By signing, both parties certify their understanding of the supervisory responsibilities and declare the provided information as true and correct under penalty of perjury under the laws of the State of California.

What should be included in the "goals and objectives" section of the Supervisory Plan?

In the "goals and objectives" section, both the supervisor and the supervisee should outline the specific learning outcomes and professional development milestones they aim to achieve during the supervisory period. This might include, but isn't limited to:

• Improvement in clinical assessment and intervention skills.
• Development of ethical decision-making.
• Enhancement of communication skills with clients, families, and other professionals.
• Increasing understanding of the supervisee's scope of practice and legal responsibilities.

These goals and objectives should be specific, measurable, achievable, relevant, and time-bound (SMART) to ensure they provide a clear path for the supervisee's growth.

How and when do I submit the original signed Supervisory Plan?

The original signed Supervisory Plan needs to be submitted by the registrant to the Board upon application for examination eligibility. It is important that the document is kept in its original form as it serves as an official record of the agreed-upon supervision. Timely submission before applying for examination eligibility is crucial, as failure to do so may result in a delay or denial of the eligibility application. To avoid any complications, ensure all sections of the form are correctly filled out and that the document is signed by both parties before submission.

When filling out the Supervisory Plan form, required by the STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY as part of the licensure process for associate clinical social workers and professional clinical counselors, individuals often make several common mistakes. These errors can delay the application process or lead to its outright rejection. Recognizing and avoiding these mistakes is crucial for a smooth application process.

1. Failing to use clear, legible handwriting or typing: Since the form must be filled out clearly in ink or typed, illegible handwriting can cause misunderstandings or processing delays.

2. Not providing complete legal names: It's important to use the full legal name for both the registrant and the licensed supervisor to ensure the Board can accurately record and recognize the individuals involved.

3. Omitting registration or license numbers: These numbers are essential for the Board to verify the identity and qualifications of both parties.

4. Leaving contact information fields blank: Complete contact details, including address and telephone numbers for both residence and business, are crucial for communication.

5. Incorrectly identifying the employment setting: It's critical to clearly mark the correct employment setting from the provided options, as each setting has specific supervisory requirements.

6. Not detailing goals and objectives: A brief but complete description of the goals and objectives for the supervision period is required to outline the direction and expectations of the supervision.

7. Forgetting to sign or date the form: Both the supervisor and the registrant must sign and date the form to certify their understanding and agreement. Unsigned or undated forms are not valid.

8. Submitting a photocopy of the signed form: The original signed form is required for application processing; photocopies are not accepted.

9. Incorrectly addressing the submission: The form must be sent to the appropriate board office. Wrongly addressed submissions can lead to unnecessary delays.

10. Not reviewing for accuracy and truthfulness: As the form is declared under penalty of perjury, ensuring that all information is accurate and true before submission is paramount.

To avoid these common mistakes, it's recommended to review the form multiple times, consult with a colleague or mentor, and ensure that all information is complete and accurate before submission. This diligence will facilitate a smoother application process with the Board.

When applied as part of a comprehensive licensure preparation process, the Supervisory Plan form plays an essential role in guiding both the supervisor and the supervisee toward a successful path in mental health licensure. This document sets the expectations and structure for the supervisory relationship. However, to better navigate this journey towards licensure, various other forms and documents often accompany the Supervisory Plan form, enhancing understanding, compliance, and readiness for licensure.

• Professional Disclosure Statement: This document provides clients and supervisees with information about the supervisor’s qualifications, approach to therapy and supervision, as well as policies regarding confidentiality and emergency procedures. It's an ethical requirement in many jurisdictions.
• Consent to Treat Form: For supervisees working directly with clients, this form is essential. It informs clients about the nature of therapy, potential risks, and benefits, as well as the supervisee's status and the involvement of a supervisor in their case.
• Confidentiality Agreement: Both the supervisor and the supervisee must sign this form to affirm their commitment to maintaining confidentiality over client information, aligning with HIPAA and other legal requirements.
• Emergency Contact Form: This document lists contact information for use in case of an emergency, ensuring that both the supervisor and supervisee have accessible, vital contacts for situations requiring immediate attention.
• Learning Contract: A learning contract outlines the objectives, goals, and tasks that the supervisee aims to achieve during their supervision period, offering a structured approach to professional growth and development.
• Log of Supervised Hours: Essential for examination eligibility, this document meticulously records the number of hours spent by the supervisee in direct patient contact, supervision, and relevant administrative tasks.
• Assessment and Evaluation Forms: These forms are used periodically throughout the supervision process to assess the supervisee’s development, competencies, and areas in need of improvement, providing structured feedback to aid in professional growth.
• Termination or Completion of Supervision Form: This form officially documents the end of the supervisory relationship, summarizing the supervisee’s accomplishments, hours completed, and attesting to their readiness (or lack thereof) for licensure.

By utilizing these documents in conjunction with the Supervisory Plan form, the supervisory process becomes more transparent, structured, and beneficial for all parties involved. These documents help ensure a thorough preparation for licensure, fostering professional growth and protecting client welfare. They serve as the foundation for a well-documented and legally sound pathway towards becoming a licensed mental health professional.

• Professional Development Plan: Similar to the Supervisory Plan, a Professional Development Plan outlines objectives and goals for an individual's career or professional growth. However, it mainly focuses on the broader aspects of a person's career development rather than the specific oversight of training and work experience required for licensure in certain professions. Both documents are used to guide and document the progression towards professional goals.

• Mentorship Agreement: This document shares similarities with the Supervisory Plan in that it formalizes the responsibility of a more experienced professional to provide guidance and support to a less experienced individual. While a Mentorship Agreement might not have the regulatory implications of the Supervisory Plan, both establish a framework for ongoing evaluation and guidance within a professional setting. The emphasis is on fostering growth and development in a supportive environment.

• Internship Contract: An Internship Contract is another document closely resembling the Supervisory Plan. Both are agreements that set the terms for professional training and experience. They outline responsibilities, goals, and objectives within a structured time frame. However, an Internship Contract is typically used in educational settings or when beginning a professional journey, detailing the specific roles and expectations for the intern and the supervisor or employer.

• Performance Improvement Plan (PIP): Although used in a different context, a Performance Improvement Plan (PIP) bears resemblance to the Supervisory Plan by setting specific objectives and timelines to achieve certain goals, especially related to improving performance in the workplace. Both documents require regular reviews and updates based on the individual’s progress. While a PIP is often implemented to address deficiencies in performance, the Supervisory Plan is more focused on meeting the requirements necessary for professional licensure.

Completing a Supervisory Plan form is a critical step for clinical social workers and professional clinical counselors in California working towards licensure. Here’s a list of dos and don'ts to guide you through the process efficiently and correctly.

• Read all instructions carefully before starting the form to ensure you understand what is required.
• Print clearly in ink or type your responses to avoid any misunderstandings or delays.
• Verify all information, such as the legal names and license numbers, to ensure accuracy.
• Discuss the goals and objectives with your supervisor before filling out the form to ensure both parties are on the same page.
• Sign and date the form in the designated areas to certify the accuracy and agreement on the supervisory plan.
• Keep a copy of the completed form for your records before submitting the original to the board.
• Submit the form by the deadline indicated by the Board of Behavioral Sciences to ensure your eligibility for examination is not delayed.

• Leave any fields blank; if a section does not apply, indicate this appropriately.
• Misrepresent any information, as this can lead to severe penalties, including the rejection of your examination eligibility.
• Forget to submit the original form to the board upon application for examination eligibility, as required.

Adhering to these guidelines will help streamline the process, ensuring that all necessary information is accurately and fully conveyed. Your attention to detail and adherence to protocols in filling out the Supervisory Plan form not only demonstrates professionalism but also ensures compliance with California's Board of Behavioral Sciences regulations.

• One common misconception about the Supervisory Plan form is that it's only necessary for those in private practice settings. In reality, professionals across various employment settings, including licensed health facilities, governmental entities, schools, and more, are required to complete it.

• Many assume the Supervisory Plan is a one-time form that doesn't need updating. However, it's critical to revise and resubmit the plan if there are any changes in the supervisory relationship or the goals and objectives of the supervision.

• Another misunderstanding is that the form applies to all mental health professionals. Specifically, it is required for associate clinical social workers, professional clinical counselor interns, and licensed mental health professionals who meet the Board's criteria.

• There's a belief that the Supervisory Plan form submission is the final step in the process. Submitting this form is just one part of the application for examination eligibility, not the culmination of the licensure process.

• Some think that digital signatures are acceptable for this form. However, the form mandates that original signatures be provided, emphasizing the need for a hardcopy with ink signatures from both the supervisor and the registrant.

• It's often misconceived that the form's primary focus is on the supervisor. While it captures supervisor details, its broader purpose is to outline the supervisory relationship, goals, and objectives—making it equally about the supervisee's professional development.

• There's a misconception that once submitted, the Supervisory Plan form won't need to be accessed again. It should be treated as a vital document, reflecting upon and guiding the supervision process, and may be needed for future reference or verification.

• Some believe the form is overly complex and difficult to complete. While it requires thoughtful input, the form itself prompts for straightforward information about the supervisory relationship, aiming to ensure clarity and compliance rather than complexity.

• A common mistake is thinking that Supervisory Plan details are only relevant to the Board. They are essential not only for compliance but also serve as a clear framework for the supervisee's training and professional growth.

• Lastly, there's the misconception that the Supervisory Plan is irrelevant to examination success. Although not a study guide, the structured experience it outlines is fundamental in preparing registrants for the responsibilities they'll face post-licensure.

Filling out and using the Supervisory Plan form accurately and thoroughly is essential for prospective clinical social workers and professional clinical counselors in California. Here are five key takeaways:

• Compliance with Regulations: The requirement for a Supervisory Plan stems from Title 16 of the California Code of Regulations (CCR) Sections 1870.1 and 1822. These sections mandate that all associate clinical social workers, professional clinical counselor interns, and licensed mental health professionals who supervise them, adhere to specific guidelines outlined by the Board of Behavioral Sciences.
• Eligibility for Examination: For registrants aiming to become licensed Clinical Social Workers or Professional Clinical Counselors, submission of the original signed Supervisory Plan is pivotal. It must be turned in upon application for examination eligibility, signifying a crucial step in the licensing process.
• Detailed Information Required: Both the registrant and the licensed supervisor must provide thorough information, including names, license numbers, employment details, and contact information. This ensures clear communication channels and formal recognition of the supervisory relationship.
• Setting Goals and Objectives: An integral part of the Supervisory Plan involves detailing the goals and objectives for the supervisory period. This forward-looking component is crucial for structuring the supervision process, guiding the developmental path of the supervisee, and ensuring alignment with professional standards and personal growth objectives.
• Legal and Ethical Responsibility: By signing the Supervisory Plan, both the supervisor and the supervisee declare under penalty of perjury that the information provided is accurate and that they understand their responsibilities. This includes the supervisor’s duty to perform ongoing assessments of the supervisee’s competence and development, underlining the seriousness and legal implications of the supervisory role.