Common use of THE PRIMARY SUPERVISOR Clause in Contracts

THE PRIMARY SUPERVISOR. Yes No Must be a licensed psychologist. ⬜ ⬜ Shall possess and maintain a valid, active license free of any formal disciplinary action, and will notify the ⬜ ⬜ trainee of any disciplinary action that affects his or her ability or qualifications to supervise. Shall be employed in the same work setting by the same employer. ⬜ ⬜ Shall be available to the trainee 100% of the time the trainee is working. This availability may be in ⬜ ⬜ person or through telephone, beeper, or other appropriate technologies. Shall complete a minimum of 6 hours of supervision coursework every 2 years as described in section ⬜ ⬜ 1387.1(b). Shall be in compliance at all times with the provisions of the Psychology Licensing Law or the Medical ⬜ ⬜ Practice Act, whichever might apply, and the regulations adopted pursuant to these laws. Shall be responsible for ensuring that the trainee is in compliance at all times with the provisions of the Psychology Licensing Law or the Medical Practice Act, whichever might apply, and the regulations adopted ⬜ ⬜ pursuant to these laws. ▇▇▇▇▇ ensure that all SPE and record keeping is conducted in compliance with the Ethical Principles and Code ⬜ ⬜ ⬜ ⬜ ⬜ ⬜ ⬜ ⬜ ⬜ ⬜ ⬜ ⬜ of Conduct of the American Psychological Association. Shall monitor the welfare of the supervisee's assigned clients. Prior to rendering services shall inform each client that the trainee is unlicensed and is functioning under the direction and supervision of the supervisor and that any fees paid for the services of the trainee must be paid directly to the primary supervisor or employer. Shall monitor the performance and professional development of the trainee and provide periodic assessments and feedback to the trainee as to whether he or she meets performance expectations. ▇▇▇▇▇ ensure that the supervisor has the education, training, and experience in the area(s) of psychological practice supervised. Shall have no familial, intimate, business, or other relationship with the trainee that would compromise the supervisor's effectiveness, and/or would violate the Ethical Principles and Code of Conduct of the American Psychological Association. ▇▇▇▇▇ not supervise a trainee who is now or ever has been a psychotherapy client of the supervisor. ⬜ ⬜ Shall not exploit or engage in sexual relationships or any other sexual contact with the trainee. ⬜ ⬜ Shall provide a copy of the pamphlet "Professional Therapy Never Includes Sex" to the trainee. ⬜ ⬜ Shall monitor the supervision performance of all delegated supervisors. ⬜ ⬜ Name: (Print or Type) License #: Signature: Date: E-mail Address: QUALIFIC ATIONS AND RESPONSIBILITIES OF DELEGATED SUPERVISORS (CCR section 1387.2 : THE DELEGATED SUPERVISOR(S): Yes No Must be a licensed psychologist or those other licensed mental health professionals listed in section 1387(c)(1). ⬜ ⬜ Shall possess and maintain a valid, active license free of any formal disciplinary action, and will notify the trainee and primary supervisor of any disciplinary action or change in license status that affects his or her ability or qualifications to supervise. ⬜ ⬜ Shall be in compliance at all times with the provisions of the Psychology Licensing Law and the regulations adopted pursuant to this law. ⬜ ⬜ Shall be responsible for ensuring compliance at all times by the trainee with the provisions of the Psychology Licensing Law and the regulations adopted pursuant to this law. ⬜ ⬜ ▇▇▇▇▇ ensure that all SPE and record keeping conducted under the supervision delegated to them is in compliance with the Ethical Principles and Code of Conduct of the American Psychological Association. ⬜ ⬜ Shall monitor the welfare of the trainee’s clients while under their delegated supervision. ⬜ ⬜ Shall be responsible for monitoring the performance and professional development of the trainee and for reporting this performance and development to the primary supervisor. ⬜ ⬜ ▇▇▇▇▇ ensure that they have the education, training, and experience in the area(s) of psychological practice to be supervised. ⬜ ⬜ Shall have no familial, intimate, business, or other relationship with the trainee that would compromise the supervisor’s effectiveness, and/or would violate the Ethical Principles and Code of Conduct of the American Psychological Association. ⬜ ⬜ ▇▇▇▇▇ not supervise a trainee who is now or ever has been a psychotherapy client of the supervisor. ⬜ ⬜ Shall not exploit or engage in sexual relationships, or any other sexual contact with the trainee. ⬜ ⬜ I understand and accept this agreement, including, but not limited to, my duties and responsibilities as a delegated supervisor and will ensure to the best of my abilities that the trainee and I will comply with the terms and conditions of this agreement. All the foregoing is true, complete, and correct. Name (Print or Type): License #: Signature: Date: City & State: Name (Print or Type): License #: Signature: Date: City & State: Name (Print or Type): Signature: Date: Address: City & State: Phone: E-mail Address:

THE PRIMARY SUPERVISOR. Yes No Must be a licensed psychologist. ⬜ ⬜ F F Shall possess and maintain a valid, active license free of any formal disciplinary action, and will notify the ⬜ ⬜ F F trainee of any disciplinary action that affects his or her ability or qualifications to supervise. Shall be employed in the same work setting by the same employer. ⬜ ⬜ F F Shall be available to the trainee 100% of the time the trainee is working. This availability may be in ⬜ ⬜ F F person or through telephone, beeper, or other appropriate technologies. Shall complete a minimum of 6 hours of supervision coursework every 2 years as described in section ⬜ ⬜ F F 1387.1(b). Shall be in compliance at all times with the provisions of the Psychology Licensing Law or the Medical ⬜ ⬜ F F Practice Act, whichever might apply, and the regulations adopted pursuant to these laws. Shall be responsible for ensuring that the trainee is in compliance at all times with the provisions of the Psychology Licensing Law or the Medical Practice Act, whichever might apply, and the regulations adopted ⬜ ⬜ F F pursuant to these laws. ▇▇▇▇▇ ensure that all SPE and record keeping is conducted in compliance with the Ethical Principles and Code ⬜ ⬜ ⬜ ⬜ ⬜ ⬜ ⬜ ⬜ ⬜ ⬜ ⬜ ⬜ F F of Conduct of the American Psychological Association. Shall monitor the welfare of the supervisee's assigned clients. F F Prior to rendering services shall inform each client that the trainee is unlicensed and is functioning under the direction and supervision of the supervisor and that any fees paid for the services of the F F trainee must be paid directly to the primary supervisor or employer. Shall monitor the performance and professional development of the trainee and provide periodic F F assessments and feedback to the trainee as to whether he or she meets performance expectations. ▇▇▇▇▇ ensure that the supervisor has the education, training, and experience in the area(s) of F F psychological practice supervised. Shall have no familial, intimate, business, or other relationship with the trainee that would F F compromise the supervisor's effectiveness, and/or would violate the Ethical Principles and Code of Conduct of the American Psychological Association. ▇▇▇▇▇ not supervise a trainee who is now or ever has been a psychotherapy client of the supervisor. ⬜ ⬜ F F Shall not exploit or engage in sexual relationships or any other sexual contact with the trainee. ⬜ ⬜ F F Shall provide a copy of the pamphlet "Professional Therapy Never Includes Sex" to the trainee. ⬜ ⬜ F F Shall monitor the supervision performance of all delegated supervisors. ⬜ ⬜ Name: (Print or Type) License #: Signature: Date: E-mail Address: QUALIFIC ATIONS AND RESPONSIBILITIES OF DELEGATED SUPERVISORS (CCR section 1387.2 : THE DELEGATED SUPERVISOR(S): Yes No Must be a licensed psychologist or those other licensed mental health professionals listed in section 1387(c)(1). ⬜ ⬜ Shall possess and maintain a valid, active license free of any formal disciplinary action, and will notify the trainee and primary supervisor of any disciplinary action or change in license status that affects his or her ability or qualifications to supervise. ⬜ ⬜ Shall be in compliance at all times with the provisions of the Psychology Licensing Law and the regulations adopted pursuant to this law. ⬜ ⬜ Shall be responsible for ensuring compliance at all times by the trainee with the provisions of the Psychology Licensing Law and the regulations adopted pursuant to this law. ⬜ ⬜ ▇▇▇▇▇ ensure that all SPE and record keeping conducted under the supervision delegated to them is in compliance with the Ethical Principles and Code of Conduct of the American Psychological Association. ⬜ ⬜ Shall monitor the welfare of the trainee’s clients while under their delegated supervision. ⬜ ⬜ Shall be responsible for monitoring the performance and professional development of the trainee and for reporting this performance and development to the primary supervisor. ⬜ ⬜ ▇▇▇▇▇ ensure that they have the education, training, and experience in the area(s) of psychological practice to be supervised. ⬜ ⬜ Shall have no familial, intimate, business, or other relationship with the trainee that would compromise the supervisor’s effectiveness, and/or would violate the Ethical Principles and Code of Conduct of the American Psychological Association. ⬜ ⬜ ▇▇▇▇▇ not supervise a trainee who is now or ever has been a psychotherapy client of the supervisor. ⬜ ⬜ Shall not exploit or engage in sexual relationships, or any other sexual contact with the trainee. ⬜ ⬜ I understand and accept this agreement, including, but not limited to, my duties and responsibilities as a delegated supervisor and will ensure to the best of my abilities that the trainee and I will comply with the terms and conditions of this agreement. All the foregoing is true, complete, and correct. Name (Print or Type): License #: Signature: Date: City & State: Name (Print or Type): License #: Signature: Date: City & State: Name (Print or Type): Signature: Date: Address: City & State: Phone: E-mail Address:F F