NORTH DAKOTA BOARD OF COUNSELOR EXAMINERS


CLINICAL SUPERVISION VERIFICATION
(Practica-Internships)

All applicants applying for the Licensed Professional Clinical Counselor (LPCC) license must have completed 800 hours of clinical training in Supervised Practica and/or Internships relevant to the practice of clinical counseling.

These hours may be within the required sixty (60) graduate semester hours. Written verification must be provided by the clinical supervisor on this form.

SUPERVISION REPORT FORM

Supervisee's Name: ________________________________________________
Supervisee's Address: ________________________________________________
Agency or Office: ________________________________________________
Job Title: ________________________________________________

This form records the supervision received by the above named Licensed Professional Counselor (LPC). The information on the attached pages (the date, method of supervision, and number of hours) is summarized in the space below. As supervisor, you are asked to verify the accuracy of this information and make a recommendation regarding licensure of this individual as a Licensed Professional Clinical Counselor (LPCC).

Summary of Supervision

 
Number of Hours of Individual Supervision: ___________
Number of Hours of Group Supervision: ___________
Total Number of Hours of Supervision: ___________

This supervisee has received the number of hours of individual and group supervision recorded on the attached pages and summarized above.

I recommend or do not recommend (circle one) this person for licensure as a licensed professional counselor.

Supervisor’s Signature: ________________________________________________
Print or Type Name: ________________________________________________
Job Title: ________________________________________________
Professional Credentials: ________________________________________________
Date Signed: ________________________________________________

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