Get Supervised Experience Attestation Form-fall 2013

Filling out the Supervised Experience Attestation Form-Fall 2013 online can be a straightforward process. This guide provides step-by-step instructions to facilitate the completion of the form, ensuring clarity and accuracy.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by filling in your information as the applicant. Provide your name and intern registration number in the designated fields. Ensure that the information is printed clearly or typed for legibility.
3. The supervisor should complete their general information portion. This includes the supervisor's name, phone number, address, license or certification title, state, original licensure date, and license number.
4. Next, the supervisor must enter details regarding any other professional credentials, including the organization, date of original certificate, and certification number.
5. In the supervised experience affirmation section, the supervisor must confirm their understanding of the relevant rules. They should note the supervision period by filling in the start and end dates, and confirm the total number of weeks of supervision provided.
6. The number of hours of psychotherapy provided by the intern each week should be indicated in the provided space.
7. If applicable, the supervisor must check the box indicating their intent to continue providing supervision until the intern is fully licensed or note if they are no longer providing supervision with the corresponding date.
8. The supervisor must assess the intern's performance and check the appropriate box that reflects their opinion. If the minimum standards have not been met, additional information explaining the circumstances must also be provided.
9. The supervisor must then add their original signature and date the form. This section must be completed by the supervisor, not just signed.
10. Once all the required fields are filled out, review the form for accuracy. You can then save changes, download, print, or share the completed form as needed.

Complete your Supervised Experience Attestation Form online today.