Ardent Grace
Counseling

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Supervision Handbook

Off-Site Supervisee Release & Acknowledgement of Responsibilities

Supervisee Information

Name Phone number

Clinical Hours Site Information

Name of site Phone number of field site

Address (include zip) Website

Site Supervisor Information

Name of site supervisor E-mail

Phone number

Instructions for Site Supervisor

How does the supervisee receive supervision at this site? What accountability does the supervisee have for clinical responsibilities?

Supervisee Release

I give my consent for Christi Kersten, LPC-S to exchange information with my site supervisor to assist with my professional growth and ensure compliance with BHEC Rules and the ACA Code of Ethics.

Supervisee signature

Associate Signature

Date

Site Supervisor Acknowledgement

Supervisee is allowed to videotape direct clinical hours performed at this site (with video release form).YesNo

Supervisee is allowed to bring clinical notes and treatment plans to supervision.YesNo

Site supervisor signature Date

Acknowledgement of Responsibilities

Please contact Christi Kersten, LPC-S if the supervisee does not comply with the following:

Being ethical with all job responsibilities

Being on time for responsibilities

Being open to feedback for responsibilities

Being a team player for the organization

Keeping accurate documentation up to date as required

Completing all job responsibilities

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© 2026 Ardent Grace Counseling · Christi Kersten, LPC-S · 713-886-6309 · therapist@ckerstenlpc.com
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