NORTH DAKOTA BOARD OF COUNSELOR EXAMINERS
(Post-Master Work Experience)

CLINICAL SUPERVISION VERIFICATION
(Practica-Internships)

All applicants applying for the Licensed Professional Clinical Counselor (LPCC) license must have completed 3000 hours of  Supervised Clinical Counseling work experience, including 100 hours of  face-to-face supervision. 

Written Verication must be provided by the clinical supervisor on this form. At least 60 hours of required total of 100 hours must be individual supervision.

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

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.