Page 1 of 5 Sample Supervision Plan / April 2019 Sample Supervision Plan Applicant's name: Jane Doe Original plan Date: March 4, 2019_______________ 1. Branch of psychology Clinical/Counselling Revised plan Date: Total # of hours in this branch (minimum of 400 hours) 1600_____ 2. Provide a description of the practice in each of the declared professional activities within this branch of psychology. Attach additional sheets as necessary. Professional activity Professional activity Professional activity Interventions Formal Assessment General Assessment # of hours # of hours # of hours 600 400 200___ presenting issues of the clients treatment details of modality and specific therapy approaches for each client characteristic a minimum of 400 hours is required for this activity assessment instruments - list all norm-referenced test instruments to be used (e.g., Wechsler Adult Intelligence Scale - Edition Number, Minnesota Multiphasic Personality Inventory - Edition Number, Wechsler Individual Achievement Purpose (e.g., to respond to referral query and/or to form a formal report) a minimum of 400 hours is required for this activity method of general assessments (e.g., clinical interview, observations, history, file review)
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Page 1 of 5 Sample Supervision Plan / April 2019
Sample Supervision Plan
Applicant's name:
Jane Doe
Original plan
Date: March 4, 2019_______________
1. Branch of psychology
Clinical/Counselling
Revised plan
Date:
Total # of hours in this branch (minimum of 400 hours)
1600_____
2. Provide a description of the practice in each of the declared professional activities within this branch of psychology. Attach additional sheets as necessary.
Professional activity
Professional activity
Professional activity
Interventions
Formal Assessment
General Assessment
# of hours
# of hours
# of hours
600
400
200___
presenting issues of the clients treatment details of modality and specific therapy approaches for each client characteristic a minimum of 400 hours is required for this activity
assessment instruments - list all norm-referenced test instruments to be used (e.g., Wechsler Adult Intelligence Scale -
Purpose (e.g., to respond to referral query and/or to form a formal report) a minimum of 400 hours is required for this activity
method of general assessments (e.g., clinical interview, observations, history, file review)
Page 2 of 5 Sample Supervision Plan / April 2019
Professional activity
Professional activity
Professional activity
Professional activity
Research
Consultation
Supervision
Teaching
# of hours
# of hours
# of hours
# of hours
100
100
100
100___
format (e.g., workshop, credit course, etc.) course content or outline supervisor’s involvement
research question(s)
population sample (who is part of the study)
Consultation Definition: “The provision of professional advice or service based on psychological knowledge, skills and judgment that will assist others in the identification and resolution of problems.”
whom you will provide consultation to purpose (e.g., rehabilitation planning, school placement) method (e.g., case conferences, telephone consults, report writing)
method of supervision from your supervisor
Page 3 of 5 Sample Supervision Plan / April 2019
3. The Standards for Supervision of Provisional Psychologists Form A states that you must spend 1 hour for every 15 hours of practice in supervision with your supervisor. Indicate below how you plan to meet this requirement and indicate the total number of hours you will spend in supervision with your supervisor.
Total # of hours: 107
4. Location where hours will be completed:
5. Primary supervisor's name and degree(s), registration/certification number and date of registration. Include this information for secondary supervisor(s) if applicable.
6. Supervisor's address and telephone number. Include this information for secondary supervisor(s) if applicable. If the supervisor is not an employee of the same agency and site as you, your employer must confirm in writing that they are in agreement with the supervision arrangement to grant your supervisor(s) access to client files you are involved with and to meet the requirement for on-site, face-to-face supervision.
7. Supervisor's employer. Include this information for secondary supervisor(s) if applicable.
City, AB T1A 2B3 (780) 123-4567
Helpful Psychological Services
There will be one hour of supervision for every 15 hours of practice.
You cannot work as a sole practitioner in a private practice setting. You must share office space with at least one
other regulated health professional. Provide the name and contact information of the individual(s).
John Supervisor, PhD, R Psych, #007, June 1, 1992
Page 4 of 5 Sample Supervision Plan / April 2019
8. The supervisor(s) will provide supervision for the applicant's work at (name agency).
Include this information for secondary supervisor(s) if applicable.
9. Period of supervision:
May 2019
to May 2020
= 12
months
Explain any interruptions during this period:
10. Dates of mid-term and final evaluations:
11. A minimum of 25% of the hours to be spent in supervision with your supervisor
will be on-site, face-to- face.
✔ Yes No
If you answered no, explain:
12. 75% of the hours to be spent in supervision with your supervisor will be individual supervision (not group supervision).
✔ Yes No
If you answered no, explain:
13. The form of monitoring and evaluation of practice will be (choose all that will apply):
✔ Face-to-Face ✔ Tape Recorded ✔ Telephone ✔ Group
✔ Case Consultation
✔ Live Observation
✔ Co-Therapy
Other
If other, explain:
Helpful Psychological Services
3 weeks vacation
Mid-term: Jan 31, 2020
Final: May 30, 2020
Page 5 of 5 Sample Supervision Plan / April 2019
14. Emergency supervision has been discussed and arranged:
Yes No
If you answered no, explain:
Applicant's Name (print)
Jane Doe
Applicant's Signature
Date
March 31, 2019
Primary Supervisor's Name (print)
Supervisor
Primary Supervisor's Signature
Date
March 31, 2019
Secondary Supervisor's Name (print) Secondary Supervisor's Signature (if applicable)
Date
Personal information is collected, used and disclosed for the purpose of registration and for other regulatory purposes in accordance with the Health
Professions Act, Personal Information Protection Act and the Privacy Policy of the College of Alberta Psychologists, which can be found on the College website at www.cap.ab.ca. Please contact the Privacy Officer of the College if you have any questions.
