Hello and Welcome!

Thank you for coming here to start the process of engagement in Clinical Supervision.

As an FYI - this form is for you to complete - and also for you to use as resource material.

As you complete this form, note that this also contains the questions that I use for all clients to ensure I have a good depth of knowledge that the clients share with me about their issues, goals and their resources,  you can choose to fill in as much or little as you like - (of course there are some questions you can skip as well as you wish).

(NB: I would like you to know,  this form is also used for those who come to me for Therapy, Training, Coaching and Mentoring services and also those Therapists who are registering for their Mandatory Clincal Supervision Services  - whether  Group, One on One Supervisions (1:1), Peer Supervision, or Supervisor Supervision)

So - signing up starts with you completing this Supervisee (Client) Intake Form. (which includes a section towards the end that comprises the formal sign up of Supervisee Contract as well)

Once this form is completed, you can expect a free (Zero Cost) 15-20 minute consultation via phone - so that we can determine the best next step for you, and at this time, we can work out the best mutually acceptable appointment time for your first supervision session. (if we haven't already done this prior to you completing this form of course)  

This form is an important first step for us both,  as it allows me to really assist you to help you get the results you want.  As you are a unique individual, answering these questions will help me to design a tailored program to identify the goals and outcomes specific to you, so we can work together to achieve these.

To ensure I get all of the important details about you,  & so we can ensure we are working within scope,  there will be some questions where I will require a response on the form.   Those questions you will see as you go along, will say that an  "Answer is required" - Please note that the form can't be submitted until those questions are answered . (as they are also an important part of my requirement as your Supervisor &/or Coach & Mentor - to be as a fully informed as possible)

Please remember and note that as a Supervisee, I am providing you with more than just a Supervisee Intake Form - as this form has many of the Questions & statements  that are included in my General Client Intake Form - so if they are valuable to you - you can Copy & paste them into a document to help you to incorporate these into your own client intake forms as you wish, (Oct 2023 version)

So, whilst you sign up as a Supervisee, part of this start up is those elements of my (general)  Client Intake Form - that you may find beneficial to add into your own Client Intake Forms at some point.  (It is no accident that this form looks a great deal like a Clinical Client Intake Form  as well as the Clinical Supervisee Intake form.  So - again - If you find helpful content - you may use it in part - as this is part of the skillsets and knowledge transfer you can expect from me, Kerry, as your Supervisor.


Contract for Clinical Supervision

Following is the formal contract by which, I, Kerry Bailey as your supervisor and you as a supervisee agree to abide  during the delivery of clinical supervision.

 

Clinical supervision can be provided as outlined by your specific professional association (usually a combination of one on one and group supervision) or if you are a newly qualified or a new service deliver practitioner you may choose supervision on a ‘as needed basis’.

 

Clinical supervision is a collaborative process during which you will be  provided with support, education and mentoring.


Our Agreed Contract for Clinical Supervision

 

The following contract is between:   Kerry Bailey of SydneyHypno & Functional Mind Coaching and the Supervisee completing this intake form.

Definition of Clinical Supervision

There is a clear definition of supervision:  it is a collaborative interpersonal process that promotes standards, teaches and  develops  theoretically knowledge and skills, including evaluating, monitoring a supervisee professional practice and consultation.

 

We agree to the following:

The purpose  of supervision is to enable the supervisee to reflect in depth on issues affecting therapeutic practice in order to develop professionally and personally towards achieving, sustaining and developing a high quality and safe service to clients.

Duties and responsibilities 

Clinical Supervisor Responsibilities

•         Encourage on-going professional education
•         Monitor basic micro-skills and advanced skills(where applicable), including transference and                  counter-transferences, duty of care, conflict of interest, duty to report 
•         Discuss/Provide alternative approaches for the supervisee where required/appropriate
•         Intervene where client welfare is at risk 
•         Ensure ethical guidelines and professional standards are maintained at all times
•         Provide consultation when necessary
•         Challenge and problem solves with supervisee
•         Discuss administrative procedures 

Supervisee Responsibilities

• It is agreed that the supervisee will (present cases, read material provided in supervision, complete supervisory tasks, keep correct logbooks if required by their professional association
• The supervisee is aware of and discuss ethical codes and professional standards of practice requirements regarding supervision relevant to the supervise 
• Uphold ethical guidelines and professional standards 
• Discuss client cases with the aid of written case notes and /or video /audio tapes (optional)
• Validate treatments made, approach and techniques used 
• Be open to change and alternative methods of practice 
• Consult with their supervisor or designated contact person in cases of emergency
• Implement professional supervisor directives in subsequent sessions 
• Maintain a commitment and take personal responsibility for education and  adhering to professional standards

 

De

Delivery & Legal Obligations:

• Depending on you Association guidelines - Clinical supervision can be delivered face to face (at the supervisors clinic) or via the phone, the  internet via Zoom, or other secure platform. This will be agreed between the supervisor and supervisee.
• The time and place for supervision meetings will be protected by ensuring privacy, time boundaries, punctuality and no interruptions. Sessions will only be cancelled with good cause and an alternative date confirmed. 
• Sessions will be guided by an agenda and agreed to by both supervisor and supervisee but will contain time for ad hoc discussion and reflection where appropriate.
• The content of supervision will not be discussed outside the session unless expressly agreed by both parties with the exception of unsafe, unethical or illegal practice being revealed.

Method of evaluation

Supervisee feedback will be provided during each session

Records will be limited to session details and major issues relevant to the professional supervision of the case.

Other considerations

• Supervisee’s written notes, diagnoses, action plans and videos may be reviewed in sessions the supervisee must ensure all confidentiality/legal requirements are adhered to
• Issues related to the supervises professional development may be discussed
• It is understood that important and critical issues experienced in the therapeutic setting will be raised and addressed in clinical supervision. Failure to raise such issues in a reasonable timeframe will be considered a breach of contract.
• This contract is subject to revision at any time, upon request by either the clinical supervisor or
• Cancellation Policy - No penalties exist if supervises cancel with a minimum 48 hours prior to a scheduled supervision - otherwise there will be a $50 penalty for cancelling within 24 hours. 
• Group & pre-paid group supervision "Make up sessions after cancellations only via joining added groups to "make up time" required)

If you have any questions - or any issues with the form - please call on M:  0412-412-881 - or email:  kerry@sydneyhypno.com.au

Then I will be able to call you back to assist you with this process if you need this help.  (please let me know on your message what would be a good time to call back as I will generally be calling you back in between client sessions)

(Please note that any forms you complete are treated as privileged and confidential - please see Privacy & Confidentiality details in this form for more information)

I look forward to our working together to reach your goals!

Thank you again, 

Kerry

SydneyHypno 

M: 0412-412-881
kerry@sydneyhypno.com.au

www.sydneyhypno.com.au