Supervisor’s address: phone: Email: Supervisor’s Supervisor’s Qualifications: Supervision was: Individual Session duration No of sessions: (minutes): Group Session duration No of sessions: (minutes): (max. 12 people) Session duration Number in Group: (minutes): This report relates to the period: to The details reported on this page give an accurate description of our supervision arrangements. The applicant has demonstrated a capacity to provide professional supervision to counsellors and/or psychotherapists and I see no obstacle to listing the applicant as an Accredited Supervisor. signature: Date: Supervisor’s Total supervision on supervision hours: Total hours of supervised signature: Date: Applicant’s client contact as a supervisor: * Please complete additional tables if you have more than one supervisor. Copy this page if required. name: Supervisor’s Supervisor’s address: phone: Email: Supervisor’s Supervisor’s Qualifications: Supervision was: Individual Session duration No of sessions: (minutes): Group Session duration No of sessions: (minutes): (max. 12 people) Session duration Number in Group: (minutes): This report relates to the period: to The details reported on this page give an accurate description of our supervision arrangements. The applicant has demonstrated a capacity to provide professional supervision to counsellors and/or psychotherapists and I see no obstacle to listing the applicant as an Accredited Supervisor. signature: Date: Supervisor’s Total supervision on supervision hours: Total hours of supervised signature: Date: Applicant’s client contact as a supervisor: * Please complete additional tables if you have more than one supervisor. Copy this page if required. PART 5: Applicant declaration I, (print name) confirm Please tick: : that: I have professional indemnity insurance cover in place and agree to maintain continuous cover for the duration of my registration.
Supervisor’s address: Supervisor’s phone: Email: Supervisor’s Qualifications: Supervision was: Individual Session duration (minutes): No of sessions: Group (max. 12 people) Session duration (minutes): No of sessions: Session duration (minutes): Number in Group: This report relates to the period: to The details reported on this page give an accurate description of our supervision arrangements. The applicant has demonstrated a capacity to provide professional supervision to counsellors and/or psychotherapists and I see no obstacle to listing the applicant as an Accredited Supervisor. Total supervision on supervision hours: Supervisor’s signature: Date: Total hours of supervised client contact as a supervisor: Applicant’s signature: Date: * Please complete additional tables if you have more than one supervisor. Copy this page if required. Supervisor’s name: Supervisor’s address: Supervisor’s phone: Email: Supervisor’s Qualifications: Supervision was: Individual Session duration (minutes): No of sessions: Group (max. 12 people) Session duration (minutes): No of sessions: Session duration (minutes): Number in Group: This report relates to the period: to The details reported on this page give an accurate description of our supervision arrangements. The applicant has demonstrated a capacity to provide professional supervision to counsellors and/or psychotherapists and I see no obstacle to listing the applicant as an Accredited Supervisor. Total supervision on supervision hours: Supervisor’s signature: Date: Total hours of supervised client contact as a supervisor: Applicant’s signature: Date: * Please complete additional tables if you have more than one supervisor. Copy this page if required. PART 5: Applicant declaration I, : (print name) confirm that: Please tick: I have professional indemnity insurance cover in place and agree to maintain continuous cover for the duration of my registration.
AccSup-Application-Form-2018-2.docx