Clinical Supervision Agreement

I am entering into an agreement with James W. Kreider, LSCSW, for clinical supervision.  As my supervisor, he will provide oversight, guidance, and direction as required by the state of Kansas in preparation for licensure at the clinical level.  I understand that clinical supervision is distinct from personal therapy, didactic instruction, or professional consultation.


I understand that my supervision is being paid for at the agreed upon rate by:

my employer, who will make payments at least monthly. 

me, and I will make payments at the time of service, or at least monthly. 


I agree to carry my own professional liability insurance policy for the duration of my supervision, and to provide my supervisor with a copy of that policy.

I agree to inform all of my clients of my level of training and licensure, that I am practicing under supervision (which means confidential information will be shared with him, however he will not share that information with any others), and of his name (phone number and address will also be provided if clients want to contact him directly regarding my practice or professional behavior in my work with them).

I have read and understand the Social Work Code of Ethics.  I agree to abide by the Code of Ethics, including having no dual, sexual, or other relationships of any type with clients or others with whom I deal in a professional capacity where power or authority issues might create the possibility of harm or exploitation, either overtly or covertly.

I understand that my supervisor will share partial responsibility for my clinical practice, only to the extent that he is informed.  As a result, I accept that I am obligated to keep him informed regarding any and every situation that may present legal, ethical, or clinical risks for my clients, myself, him, or my employing agency.  He, in turn, would then be obligated to help me consider an appropriate course of action, only if completely informed.

I understand that my supervisor will not be involved in my personnel or performance evaluation since he has only partial clinical responsibility and no administrative responsibility for my clinical practice.

I give my permission for my supervisor to discuss my supervision or issues related to my clinical practice with my clients, my employment supervisors, the Behavioral Sciences Regulatory Board, or any others to whom either he or I are professionally accountable, (which he would be ethically obligated to do) if my practice appeared in any way to be illegal, unethical, incompetent, or otherwise had the potential to put clients, myself, my agency, or any others at risk. 

The agreed upon period of supervision will begin                      and end                         .

My signature below indicates that I have read, understand, and agree with all of the preceding statements.



     Supervisee                                                        date                                                         Supervisor

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