Get Clinical Supervisor Exemption Request - Azbbheus

Completing the CLINICAL SUPERVISOR EXEMPTION REQUEST is an essential task for individuals seeking exemption status in clinical supervision. This guide provides a comprehensive, step-by-step process tailored to facilitate users through filling out the form accurately and efficiently.

Follow the steps to successfully complete your exemption request form.

1. Click the ‘Get Form’ button to obtain the exemption request form and open it in the editor.
2. Fill in your name in the designated field at the top of the form, followed by your phone number and address.
3. Provide your current AzBBHE license number along with its expiration date in the respective fields.
4. Select one of the two options regarding your application status. Indicate whether you have submitted an application for licensure or if you anticipate applying for independent level licensure in the future. Be sure to fill in the required dates for application submission or projected application.
5. Enter the name of your proposed Clinical Supervisor and detail the licenses they hold along with their expiration dates.
6. Document the agency or entity where your supervised work experience was or will be acquired, including the address and the size of the agency/entity in number of employees.
7. Indicate which exemption category applies to your request by checking the relevant box. Provide further details for your request where required.
8. Ensure to include an explanation for your request in the designated section.
9. Review the certification statement carefully. You must affirm the accuracy of the provided information by signing and dating the form at the bottom.
10. Once completed, you can save the changes, download the form, print it, or share it as needed.

Complete your CLINICAL SUPERVISOR EXEMPTION REQUEST form online today for a smoother application process.