Sheila​ ​M.​ ​Smith,​ ​LCSW California​ ​BBS​ ​License​ ​LCS19980 [email protected] (510)​ ​439-6683 Professional​ ​Supervision​ ​Contract Between:​ ​Sheila​ ​M.​ ​Smith,​ ​LCSW​ ​and​ ​_______________________ From:(date)​ ​_______________​ ​until:​ ​(date)_____________. The​ ​Purpose​ ​of​ ​Supervision:​ ​Supervision​ ​is​ ​a​ ​mentoring​ ​relationship​ ​created to​ ​assist​ ​you​ ​in​ ​the​ ​development​ ​and​ ​enhancement​ ​of​ ​your​ ​professional practice​ ​and​ ​to​ ​provide​ ​you​ ​with​ ​appropriate​ ​support.​ ​You​ ​as​ ​supervisee retain​ ​responsibility​ ​for​ ​your​ ​own​ ​professional​ ​practice. Practicalities:​ ​We​ ​will​ ​participate​ ​in​ ​online​ ​supervision​ ​for​ ​one​ ​60​ ​minute hour​ ​at​ ​a​ ​time​ ​to​ ​be​ ​arranged​ ​at​ ​the​ ​end​ ​of​ ​each​ ​supervision​ ​session.​ ​We agree​ ​that​ ​our​ ​online​ ​supervision​ ​will​ ​be​ ​protected​ ​according​ ​to​ ​our​ ​agreed guidelines​ ​of​ ​confidentiality,​ ​as​ ​stated​ ​below. Fees:​ ​The​ ​cost​ ​of​ ​one​ ​hour​ ​of​ ​live​ ​supervision​ ​is​ ​to​ ​be​ ​paid​ ​according​ ​to​ ​the schedule.​ ​The​ ​form​ ​of​ ​payment​ ​is​ ​to​ ​be​ ​agreed​ ​upon​ ​before​ ​the​ ​online supervision​ ​session​ ​begins.​ ​ ​You​ ​may​ ​pay​ ​one​ ​month​ ​in​ ​advance​ ​for​ ​a discount​ ​of​ ​five​ ​percent. 30​ ​Minute​ ​In-Office​ ​Counseling​ ​or​ ​Supervision​ ​Session

$50.00

60​ ​Minute​ ​In-Office​ ​Counseling​ ​or​ ​Supervision​ ​Session

$100.00

30​ ​Minute​ ​Online​ ​Counseling​ ​or​ ​Supervision​ ​Session​ ​– chat/audio/video

$50.00

60​ ​Minute​ ​Online​ ​Counseling​ ​or​ ​Supervision​ ​Session​ ​– chat/audio/video

$75.00

Email​ T ​ herapy​ E ​ xchange​ ​(One-Off) Email​ T ​ herapy​ P ​ ackage​ ​of​ ​4​ ​Exchanges Email​ T ​ herapy​ P ​ ackage​ ​of​ ​8​ ​Exchanges Missed​ ​appointment​ ​fee

$50.00 $300.00 $550.00 $75.00

Please​ ​Initial​ ​here​ ​to​ ​acknowledge​ ​fees​ ​____________ 1

Cancellation​ ​of​ ​a​ ​session:​ ​Either​ ​party​ ​is​ ​to​ ​provide​ ​no​ ​less​ ​than​ ​24​ ​hours notice​ ​in​ ​the​ ​event​ ​of​ ​cancellation.​ ​ ​If​ ​the​ ​minimum​ ​24​ ​hour​ ​notice​ ​is​ ​not given,​ ​a​ ​missed​ ​appointment​ ​fee​ ​will​ ​be​ ​charged​ ​according​ ​to​ ​the​ ​schedule​ ​of fees. Record​ ​keeping:​ ​All​ ​material​ ​created​ ​in​ ​the​ ​supervisory​ ​relationship​ ​is​ ​the property​ ​of​ ​the​ ​supervisor​ ​and​ ​supervisee.​ ​Records​ ​are​ ​kept​ ​in​ ​a​ ​secure​ ​filing system​ ​on​ ​the​ ​computer,​ ​flash​ ​drive​ ​or​ ​in​ ​the​ ​supervisor’s​ ​office.​ ​Supervisee is​ ​responsible​ ​for​ ​keeping​ ​track​ ​of​ ​the​ ​hours​ ​required​ ​by​ ​the​ ​Board​ ​of Behavioral​ ​Science​ ​for​ ​eligibility​ ​to​ ​take​ ​the​ ​licensing​ ​exams. Confidentiality:​ ​The​ ​content​ ​of​ ​our​ ​meetings​ ​is​ ​confidential.​ ​ ​I​ ​receive supervision​ ​on​ ​my​ ​work.​ ​It​ ​may​ ​be​ ​that​ ​I​ ​discuss​ ​with​ ​my​ ​supervisor​ ​some of​ ​our​ ​work​ ​together.​ ​Anonymity​ ​will​ ​be​ ​maintained​ ​as​ ​far​ ​as​ ​practically possible.​ ​If​ ​there​ ​is​ ​any​ ​cause​ ​for​ ​concern​ ​regarding​ ​confidentiality,​ ​then​ ​I will​ ​discuss​ ​these​ ​matters​ ​with​ ​you​ ​first,​ ​and​ ​only​ ​with​ ​your​ ​agreement,​ ​will concerns​ ​be​ ​taken​ ​outside​ ​of​ ​our​ ​supervisory​ ​relationship. Feedback​ ​and​ ​evaluation:​ ​We​ ​will​ ​evaluate​ ​our​ ​work​ ​together​ ​and​ ​give​ ​one another​ ​feedback​ ​on​ ​a​ ​regular​ ​basis​ ​to​ ​ensure​ ​we​ ​make​ ​the​ ​most​ ​of​ ​our​ ​time together. Conflict​ ​between​ ​us:​ ​We​ ​will​ ​discuss​ ​any​ ​issues​ ​with​ ​openness​ ​and​ ​honesty, and​ ​with​ ​the​ ​intention​ ​of​ ​resolution.​ ​If​ ​the​ ​conflict​ ​cannot​ ​be​ ​resolved between​ ​us​ ​then​ ​a​ ​process​ ​for​ ​resolution​ ​will​ ​be​ ​actioned,​ ​and​ ​agreed​ ​upon, with​ ​external​ ​support​ ​for​ ​both​ ​parties​ ​being​ ​made​ ​available​ ​through mediation​ ​or​ ​arbitration​ ​as​ ​available. Making​ ​a​ ​complaint​ ​(with​ ​regard​ ​to​ ​my​ ​ethical​ ​practice):​ ​The​ ​supervisee​ ​has available​ ​to​ ​them​ ​the​ ​complaint​ ​service​ ​of​ ​the​ ​California​ ​Board​ ​of​ ​Behavioral Science.​ ​If​ ​the​ ​complaint​ ​is​ ​of​ ​a​ ​personal​ ​nature​ ​against​ ​me​ ​it​ ​is​ ​expected that​ ​we​ ​will​ ​use​ ​the​ ​conflict​ ​resolution​ ​process​ ​stated​ ​above.​ ​We​ ​agree​ ​to work​ ​together​ ​within​ ​these​ ​terms​ ​and​ ​conditions. Cancellation​ ​of​ ​this​ ​contract​ ​may​ ​be​ ​instituted​ ​by​ ​either​ ​party​ ​with​ ​one week's​ ​notice. ______________________________Clinical​ ​Supervisor,​ ​Dated: ______________________________Supervisee,​ ​Dated: When​ ​complete,​ ​please​ ​scan​ ​and​ ​email​ ​both​ ​pages,​ ​and​ ​send​ ​to [email protected]​ ​or​ ​mail​ ​to:​ ​S.Smith,​ ​LCSW,​ ​1362​ ​Pine​ ​St.,​ ​Pittsburg, CA​ ​94565. 2