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Supervisee Leave of Absence Agreement

Documents a requested leave of absence from supervision longer than one month.

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Associate Information

Associate Name

Date Submitted

Leave Details

Leave Start Date

Expected Return Date

Reason for Leave (optional)

Plan for Client Coverage / Continuity of Care During Leave

Acknowledgment

I understand that supervision hours will not accrue during this period of leave. I understand I am responsible for maintaining any required client coverage and notifying clients as appropriate. I understand that a leave of absence longer than one month requires this documented agreement between Associate and Supervisor.

Associate Signature

Date

Supervisor Signature (Christi Kersten, MA, LPC-S)

Date

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