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Get FL DH-MQA 1181 2015-2024

SUPERVISED EXPERIENCE ATTESTATION FORM Print clearly or type the following information Applicant s Name Intern Registration No. Clinical Social Work Marriage Family Therapy Mental Health Counseling Supervisor s General Information to be completed by supervisor Supervisor s Name Phone Address License/Certification Title State Original Licensure Date License Number Other Professional Credential Organization Original Certificate Date Certification Number Supervised Experience Affirmation to be completed by supervisor I have read and understand Rule Chapter 64B4-2 F.A. C. I provided at least one 1 hour of supervision per fifteen 15 hours of psychotherapy face-to-face with clients provided by the intern with a minimum of one 1 hour of supervision every two 2 weeks. Supervision was provided from // to // for a total of weeks. The applicant provided psychotherapy face-to-face with clients for hours per week. I intend to continue to provide supervision until the registered intern is fully licensed pursuant to Section 491. 0045 3 Florida Statutes and Rule 64B4-3. 008 F*A. C. If this status changes before the intern is fully licensed I will notify the board office in writing of the date I stopped providing supervision* I am no longer providing this registered intern with supervision as of Month Day Year Each blank line and one box in this section must be completed* ONE BOX BELOW MUST BE CHECKED As a professional licensee overseeing the supervision of this intern do you have any information regarding this registered intern s ability to practice and/or counsel independently Please check one of the following that most closely reflects your opinion as the supervisor overseeing the internship* Has met the minimum standards of performance in professional activities when measured against generally prevailing peer performance pursuant to Section 491. 009 1 r Florida Statutes. Has not met the minimum standards of performance in professional activities when measured against generally If you have chosen has not met you must provide further information as to why this requirement has not been met. Supervisor s Signature must be original signature Date This form is to be COMPLETED not just signed by the SUPERVISOR Florida Department of Health Division of Medical Quality Assurance Board of Clinical Social Work Marriage Family Therapy Mental Health Counseling 4052 Bald Cypress Way Bin C-08 Tallahassee FL 32399-3258 PHONE 850/245-4474 FAX 850/921-5389 Rule 64B4-3. 0015 DH-MQA 1181 Revised 04/15 www. FloridaHealth. gov TWITTER HealthyFLA FACEBOOK FLDepartmentofHealth YOUTUBE fldoh FLICKR HealthyFla PINTEREST HealthyFla. C. I provided at least one 1 hour of supervision per fifteen 15 hours of psychotherapy face-to-face with clients provided by the intern with a minimum of one 1 hour of supervision every two 2 weeks. Supervision was provided from // to // for a total of weeks. The applicant provided psychotherapy face-to-face with clients for hours per week. Supervision was provided from // to // for a total of weeks. The applicant provided psychotherapy face-to-face with clients for hours per week. I intend to continue to provide supervision until the registered intern is fully licensed pursuant to Section 491. .

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