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Off-Site Supervisee Release & Acknowledgement of Responsibilities

For Associates accruing hours at an outside site; site info, release, and responsibilities.

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Associate Information

Associate Name

Date

Off-Site Location Details

Site / Agency Name

Site Address

On-Site Contact / Site Supervisor Name

Site Contact Phone

Description of Duties / Services Provided at This Site

Release & Acknowledgement of Responsibilities

I authorize the site named above to communicate with my LPC Supervisor regarding my clinical activities at this location, as needed for supervisory oversight. I understand that I remain responsible for ensuring my Supervisor has access to relevant documentation from my work at this site. I understand that I am responsible for complying with this site's policies in addition to the terms of my supervision agreement. I understand that hours accrued at this site are subject to the same BHEC/TSBEPC requirements as hours accrued elsewhere.

Associate Signature

Date

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

Date

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