PDF Verification of Supervised Professional Practice Form 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the applicant's name at the top of the form. Ensure you print or type using black ink for clarity.
3. In the General Information section, provide the supervisor’s name, title, agency name, license type and number, mailing address, issue date, business phone, and email address.
4. For the Supervised Professional Practice section, indicate the supervision period and check all applicable modalities of supervision used.
5. Complete the hours for indirect and direct counseling as well as individual and group clinical supervision according to the guidelines provided.
6. In the Supervision Summary section, summarize supervision activities and identify strengths and potential deficits of the supervisee. Attach additional pages if necessary.
7. Rate the applicant in the Professional Assessment section using the provided scale for various characteristics.
8. Indicate your recommendation for licensure in the Reference section and provide reasons if not recommending.
9. Finally, verify all information is accurate in the Verification section by signing and dating before enclosing it in a sealed envelope.

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