OLD-E. Informed Consent of Supervision

This is to inform you that I am licensed as a social worker/counselor/marriage and famiy therapist in the State of Ohio.  I am either not Independently Licensed or not fully credentialed and therefore I require supervision by an Independently Licensed Clinical Therapist with Supervisor credentials.   
 

Therapist's Name

Supervisor's Name

Therapist Name: your therapist's name *
Therapist License Number: therapist license number*
Therapist Title: therapist title*

Supervisor Name:supervisor's full name*
Supervisor License Number: supervisor license number*
Supervisor Title: supervisor title*

Do you have a secondary supervisor?

YesNo

Secondary Supervisor's Name

Secondary Supervisor Name:2nd supervisor name*
Secondary Supervisor License Number: 2nd supervisor number*
Secondary Supervisor Title: 2nd supervisor title*

I am required to review my caseload with my clinical supervisor and/or clinical director in order to gain insight, training, and feedback in providing quality therapeutic services to you.  Signing below gives me consent to share confidential information with my supervisor and/or clinical director only for the purpose of clinical training and oversight. My clinical supervisor will have the ability to access your record to review documentation and sign off for billing purposes. Please be advised that your insurance claims will be billed under the above supervisor’s name.  
 
Signing below signifies that you understand I am under supervision and gives consent for me to work with you as your therapist. 

Client Printed Name:*

Parent/Guardian Printed Name:

Client: *

Parent/Guardian:

Date*

Date