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Clinical Supervision Plan - NC - clinical supervision case presentation format



Sample Clinical Supervision Log

Name of Supervisee:______________________________________

Name of Clinical Supervisor:________________________________


12 Core Functions
Performance Domains

1. Screening: Determination of a client’s appropriateness and eligibility for admission to a particular
program

Assessment of Supervisee:




Circle One: Group Supervision Individual Supervision Direct Observation.
Date: Duration of Session
Signatures:
2. Intake: Administration and initial assessment procedures for admission to a program.

Assessment of Supervisee:




Circle One: Group Supervision Individual Supervision Direct Observation
Date: Duration of Session
Signatures:
3. Orientation: Describing the general nature and goals of the program.

Assessment of Supervisee




Circle One: Group Supervision Individual Supervision Direct Observation
Date: Duration of Session
Signatures:
4. Assessment: Procedures in which the client’s needs, strengths and weaknesses, are identified
For the development of a treatment plan.

Assessment of Supervisee



Circle One: Group Supervision Individual Supervision Direct Observation
Date: Duration of Session
Signatures:
5. Treatment Planning: Client and counselor identify and rank problems, establish agreed upon
Goals, and decide on treatment methods to be used.

Assessment of Supervisee




Circle One: Group Supervision Individual Supervision Direct Observation
Date: Duration of Session
Signatures:
6. Counseling: Utilization of skills to assist individuals, families or groups to achieve objectives

Assessment of Supervisee




Circle One: Group Supervision Individual Supervision Direct Observation
Date: Duration of Session
Signatures:
7. Case Management: Bringing resources and people together within a planned framework
of action to achieve established goals.

Assessment of Supervisee




Circle One: Group Supervision Individual Supervision Direct Observation
Date: Duration of Session
Signatures:
8. Crisis Intervention: Response to Client’s needs during acute distress.

Assessment of Supervisee




Circle One: Group Supervision Individual Supervision Direct Observation
Date: Duration of Session
Signatures:
9. Client Education: Providing information regarding alcohol and drug abuse to client.

Assessment of Supervisee



Circle One: Group Supervision Individual Supervision Direct Observation
Date: Duration of Session
Signatures:
10. Referral: Assisting the client to utilize the support system and community resources available
to meet their needs.

Assessment of Supervise:




Circle One: Group Supervision Individual Supervision Direct Observation
Date Duration of Session
Signatures:
11. Report and Record Keeping:
Charting the results of the assessment and treatment plan; writing reports, progress
plan; writing reports, progress notes, discharge summaries, and other client-related data

Assessment of Supervisee




Circle One: Group Supervision Individual Supervision Direct Observation.
Date: Duration of Session:
Signatures:
12. Consultation: Relating with professionals in regards to client treatment/services, to ensure
quality client care.

Assessment of Supervisee




Circle One: Group Supervision Individual Supervision Direct Observation
Date: Duration of Session
Signatures: