Fillable Form

Performance Improvement Plan

Used when concerns arise about an Associate’s competence, ethics, or compliance.

Associate Information

Associate Name

Date

Area(s) of Concern

Clinical competence Ethical conduct Documentation Professionalism Compliance with Board rules or supervision agreement Other

Plan Details

Description of Concern

Specific Goals

Action Steps / Activities

Timeline for Review

Follow-Up Review Date

Evaluation Criteria for Success

Acknowledgment

I have reviewed and discussed this plan with my Supervisor and understand the concerns, goals, and timeline outlined above. I understand that failure to make satisfactory progress may result in modification or termination of the supervisory relationship.

Associate Signature

Date

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

Date

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