Create Your Documentation File | Ardent Grace Counseling

Associate Information

Associate Name

Date File Started

Beginning Supervision

Copy of current LPC-Associate license on file Executed Supervision Agreement / Professional Disclosure Statement Proof of professional liability (malpractice) insurance EIN / business registration information (if self-employed) Signed Emergency Consultation Guidelines acknowledgment Signed Telehealth Informed Consent (if applicable)

Ongoing Supervision

Weekly Associate Notes and Topics for Discussion submitted before each session Supervision Hours Log updated and current Client Disclosure of Supervised Status obtained for active clients Documentation/records reviewed as requested by Supervisor Continuing education tracked, where applicable

Ending Supervision

Final Supervision Hours Log submitted and reviewed Final Associate Evaluation completed Client transition or transfer plan documented, if applicable Supervisor sign-off submitted to BHEC, if applicable

Professional Liability Insurance Information

Insurance Carrier

Policy Number

Coverage Amount

Expiration Date