Both parties should have a copy of this agreement. Part A: To Be Completed by Both Parties 1. Supervisee Name: 2. Mailing Address: Street: City: State: Zip: Phone: Email: 3. Licensure Level: Lic #.
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How to fill out the MN Professional Matrix Social Work Supervision Agreement online
The MN Professional Matrix Social Work Supervision Agreement is an essential document designed for supervisors and supervisees in the field of social work. This guide provides clear, step-by-step instructions to effectively fill out the agreement online, ensuring both parties understand their rights and responsibilities.
Follow the steps to complete your Supervision Agreement online.
- Press the ‘Get Form’ button to access the MN Professional Matrix Social Work Supervision Agreement and open it in your preferred editor.
- In Part A, both parties should fill out their personal information. Start with the 'Supervisee Name' followed by the mailing address, including the street, city, state, and zip code. Also, provide the phone number and email address.
- Next, indicate the 'Licensure Level' by providing the license number, issue date, and expiration date. Select 'Yes' or 'No' for if you hold any other licenses or certifications, filling in the details as necessary.
- Proceed to enter the 'Name of Supervisor' along with their mailing address, phone number, and email, similar to how you filled in the supervisee's details.
- Again, specify the 'Licensure Level' for the supervisor and confirm if they hold additional licenses or certifications.
- Fill in the location where supervision will take place and outline the responsibilities and rights of each party in the provided fields.
- Detail the parameters of confidentiality in the corresponding section.
- In Part B, describe the duties the supervisee plans to perform in their workplace. If applicable, answer whether the supervisee’s employment includes the diagnosis and treatment of mental and emotional disorders.
- Provide the proposed dates for supervision, specifying the start and end dates.
- Outline the supervision goals in the designated area.
- In Part C, the supervisor should list their areas of professional competence and describe the nature of the supervision to be provided.
- Confirm if the supervisor's practice includes the diagnosis and treatment of mental and emotional disorders, explaining if necessary. Additionally, they should describe their training in supervision.
- Indicate whether the supervisor has completed the required 30 hours of supervision training and state their intentions for future training, if applicable.
- Check the content areas where the supervisor can provide supervision, and add any additional comments.
- Both the supervisor and the supervisee must read and agree to the statements provided, sign, and date the agreement.
- Finally, ensure all changes are saved. You may choose to download, print, or share the completed agreement as needed.
Complete your MN Professional Matrix Social Work Supervision Agreement online today!
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