Supervision Plan

Supervision Plan

Form A.2

Supervision Plan

It is the responsibility of both the supervisor and the supervisee to ensure that all practice and supervision adheres to the CASW Code of Ethics and the ACSW Standards of Practice.

Instructions

  • This form must be completed on a computer; space will expand as needed
  • This plan is to be completed by the person applying to be on the Clinical Social Work Registry
  • This plan must be signed by the applicant and the Clinical Supervisor of Record
  • The Clinical Supervisor of Record must be an Approved Clinical Supervisor OR an Approved Clinical Supervisor of Record (see Form C.1)
  • This plan must be submitted as part of the initial application
  • This form must be signed and dated
  • Direct clinical practice hours will not be counted until this plan is approved by the Clinical Committee
  • Any subsequent changes to the supervision plan or the clinical supervisor of record must be approved in advance by the Clinical Committee

Applicant Information

Full Name: / RSW#:
Email Address:
Employer(s):

Supervisor Information

Supervisor of Record: / Credentials:
Primary Number: / Alternate Number:
Email Address:
Other Clinical Supervisor(s): / Credentials:
Primary Number: / Alternate Number:
Email Address:

Supervision Details

Individual / Group / Case Consultation
Type or Method of Supervision
Start/End Dates
Frequency/Duration
Location
Provided by whom
Clinical Social Work is a mental health profession based on the application of knowledge and theory of “psychosocial development, behaviour, psychopathology, unconscious motivation, interpersonal relationships and environmental stress”*. It utilizes social work methods to assess, diagnose and provide psychotherapeutic interventions across the lifespan with individuals, couples, families and groups. Clinical Social Workers demonstrate a commitment to continue competence, ethical practice and respect for diversity.
Clinical social workers who have received the appropriate training are qualified to use the Diagnostic and Statistical Manual of Mental Disorders (DSM), International Classification of Diseases (ICD), Person-in-Environment Classification System (PIE), and other diagnostic classification systems, psychometric instruments, and personality inventories, in assessment, diagnosis, treatment, and other activities.
* National Institute for Clinical Social Work Advancement (as cited in Handbook of Clinical Social Work Supervision (3rd edition) Carlton E. Munson, PhD p. 9.)
  1. What clinical social work activities are part of your current regular practice? (Refer to the above definition in your response)

  1. Please give an example of how you demonstrated ethical practice.

  1. What theories, models and perspectives inform your clinical social work practice?

  1. What factors do you consider in developing a case formulation?

  1. What are the treatment interventions that you currently use?

Learning Objectives and Outcomes

List your learning objectives to develop or enhance your clinical social work practice (be specific with how these objectives will advance your practice)
Clinical Practice Objectives
(Examples: diagnosis, assessment, and treatment) / Clinical PracticeOutcomes
(How will these be measured?)
1.
2.
3.
  1. Describe the practice environment where the above learning objectives will be met, and the clientele to be served.

  1. How will the clinical supervision be recorded/documented?

  1. Is there anything more the committee should know about your practice or your supervision plan?

Applicant Signature: / Date:
Clinical Supervisor of Record Signature: / Date:

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Updated November 2017