Supervision Handbook

Client Disclosure of Supervised Status

Please initial each statement to indicate your understanding.

Initials — I understand I am seeing an LPC Associate; Texas requires 1,500 hours of direct client contact for full licensure. Initials — I understand my counselor participates in weekly clinical supervision with the supervisor listed below. Initials — I understand I may contact the supervisor directly with any questions or concerns.

Supervising Clinician

Christi Kersten, MA, LPC-S · Ardent Grace Counseling
25420 Kuykendahl Road, Suite B100, Office 114, Tomball, TX 77375
713-886-6309 · therapist@ckerstenlpc.com

Treating Associate name LPC Associate license #

Client's printed name Date

Signature of client, or parent/guardian if under 18

“Email this” opens your device's email app with everything below filled in and addressed to Ardent Grace Counseling — just hit Send. Nothing is transmitted automatically or stored on this page.