Hello and Welcome!

Thank you for coming here to start the process of engagement in Clinical Supervision.

Signing up starts with you completing this Supervisee (Client) Intake Form. (which includes the formal sign up of your Supervision Contract as well)

As an FYI - this Supervision Intake Form also incorporates much of my own Clinical Client Intake form.  This form has many of the Questions & statements  that are included in my General Client Intake Form - in case are useful to you -perhaps to add into your own Client Intake Forms at some point. 

It is no accident that this form looks a great deal like a Clinical Client Intake Form  as well as the Clinical Supervisee Intake form, as this is part of the skillsets and knowledge transfer you can expect from me,  as your Supervisor.. This inclusion of elements of my Client Intake form, is done so that you not only have visibility of what I gather as valuable intel from clients, but also because allows you to see and determine if any of these elements is potentially useful to you as you review for inclusion to your own client intake forms.
(Handy hint - you may wish to Copy & Paste some sections/element into a document to help you to incorporate these into your own client intake forms as you wish, (Oct 2024 version)

As your Supervisor, I am determined to provide you access to potentially valuable resources from this point onwards, so, I welcome you to view this as  resource material - so if you find helpful content - including wording on health Funds and other relevant guidance matters, with a view to incorporating elements into your own Client Intake Forms for the future..


Thus, As you complete this form, not e it contains the questions that I use for all clients to ensure I have a good depth of knowledge that the clients share with me about their issues, goals and their resources before I meet with them,

Important note that as a Supervisee  you can choose to fill in as much or as little as you like unless the answer is deemed mandatory (if a mandatory answer * is required by not completed you will not be able to submit the form.   *   "Answer is required" - Please note that the form can't be submitted until those questions are answered . (as they are also an important part of my requirement as your Supervisor &/or Coach & Mentor - to be as a fully informed as possible)

Non Mandatory questions can be skipped, so long as your contact details and your contractual understandings and agreements are all completed..

Once this form is completed, you can expect a free (Zero Cost) 15-20 minute consultation via phone, so that we can determine the best next step for you, and at this time, we can work out the best mutually acceptable appointment time for your first supervision session. (That is, IF we haven't already done our quick chat prior to you completing this form of course)  

This form is an important first step for us both,  as it allows me to really assist you to help you get the results you want.   As you are a unique individual, answering these questions will help me to design a tailored program to identify the goals and outcomes specific to you, so we can work together to achieve these.



Contract for Clinical Supervision

Following is the formal contract by which, I, Kerry Bailey as your supervisor and you as a supervisee agree to abide  during the delivery of clinical supervision.

 

Clinical supervision can be provided as outlined by your specific professional association (usually a combination of "one on one" and "group supervision") or if you are a newly qualified or a new practitioner you may choose supervision on a ‘as needed basis’.  

As your Supervisor, we can discuss your Association(s) Membership criteria that you will need to meet as part of your annual requirements, and that you as a Supervisee acknowledge and agree that it is incumbent on you to have read and understood your Associations Membership documentation including their stated requirements for Supervision, CPD & Code of Ethics, to ensure we help you to meet this stated criteria.

 

Clinical supervision is a collaborative process during which you will be  provided with support, education and mentoring.


Our Agreed Contract for Clinical Supervision

 

The following contract is between:   Kerry Bailey of SydneyHypno & Functional Mind Coaching and the Supervisee completing this intake form.

Definition of Clinical Supervision

There is a clear definition of supervision:  it is a collaborative interpersonal process that promotes standards, teaches and  develops  theoretically knowledge and skills, including evaluating, monitoring a supervisee professional practice and consultation.

Clinical Supervision can be provided as outlined by your specific professional association (usually a combination of one to one and group supervision) or if you are a newly qualified or a new service deliver practitioner you may choose supervision on an as needed basis.

 

We agree to the following:

The purpose  of supervision is to enable the supervisee to reflect in depth on issues affecting therapeutic practice in order to develop professionally and personally towards achieving, sustaining and developing a high quality and safe service to clients.

Duties and responsibilities 

Clinical Supervisor Responsibilities

•         Encourage on-going professional education
•         Monitor basic micro-skills and advanced skills(where applicable), including transference                          and counter-transferences, duty of care, conflict of interest, duty to report 
•         Discuss/Provide alternative approaches for the supervisee where required/appropriate
•         Intervene where client welfare is at risk 
•         Ensure ethical guidelines and professional standards are maintained at all times
•         Provide consultation when necessary
•         Challenge and problem solves with supervisee
•         Discuss administrative procedures 

Supervisee Responsibilities

• It is agreed that the you as the supervisee will (present cases, read material provided in supervision, complete supervisory tasks, keep correct logbooks if required by their professional association
• The supervisee is aware of and discuss ethical codes and professional standards of practice requirements regarding supervision relevant to the supervise 
• Uphold ethical guidelines and professional standards 
• Discuss client cases with the aid of written case notes and /or video /audio tapes (optional)
• Validate treatments made, approach and techniques used 
• Be open to change and alternative methods of practice 
• Consult with their supervisor or designated contact person in cases of emergency
• Implement professional supervisor directives in subsequent sessions 
• Maintain a commitment and take personal responsibility for education and  adhering to professional standards
• Ensure that client confidentiality is maintained at all times. (Client details to be de-identified &/or redacted in any sessions, meetings, discussions and documents or other written communications whether analogue or digital in nature)

 

De

Delivery & Legal Obligations:

• Depending on you Association guidelines - Clinical supervision can be delivered face to face (at the supervisors clinic) or via the phone, the  internet via Zoom, or other secure platform. This will be agreed between the supervisor and supervisee.
• The time and place for supervision meetings will be protected by ensuring privacy, time boundaries, punctuality and no interruptions. Sessions will only be cancelled with good cause and an alternative date confirmed. 
• Sessions will be guided by an agenda and agreed to by both supervisor and supervisee but will contain time for ad hoc discussion and reflection where appropriate.
• The content of supervision will not be discussed outside the session unless expressly agreed by both parties with the exception of unsafe, unethical or illegal practice being revealed.
• Supervisees will adhere to a strict code that ensure their Clients Privacy & Confidentiality is maintained.  All case studies  /Client cases presented by Supervisees are to have the clients’ names and any possible identifying details redacted from any materials provided and de-identified in verbal or written discussions - Providing relevant case details only, if you seek more clarity, please ask as you will be guided by you supervisor.

Method of evaluation

Supervisee feedback will be provided during each session

Records will be limited to session details and major issues relevant to the professional supervision of the case.

Other considerations

• Supervisee’s written notes, diagnoses, action plans and videos may be reviewed in sessions the supervisee must ensure all confidentiality/legal requirements are adhered to
• Issues related to the supervises professional development may be discussed
• It is understood that important and critical issues experienced in the therapeutic setting will be raised and addressed in clinical supervision. Failure to raise such issues in a reasonable timeframe will be considered a breach of contract.
• This contract is subject to revision at any time, upon request by either the clinical supervisor will provide access to the contract for review.
• Cancellation Policy - No penalties exist if supervises cancel with a minimum 48 hours prior to a scheduled supervision - otherwise there will be a $50 penalty for cancelling within 24 hours. 
• Group & pre-paid group supervision "Make up sessions after cancellations only via joining added groups to "make up time" required - limits apply.

If you have any questions - or any issues with the form - please call on M:  0412-412-881 - or email:  kerry@sydneyhypno.com.au

Then I will be able to call you back to assist you with this process if you need this help.  (please let me know on your message what would be a good time to call back as I will generally be calling you back in between client sessions)

(Please note that any forms you complete are treated as privileged and confidential - please see Privacy & Confidentiality details in this form for more information)

I look forward to our working together to reach your goals!

Thank you again, 

Kerry

SydneyHypno 

M: 0412-412-881
kerry@sydneyhypno.com.au

www.sydneyhypno.com.au



Payment Details:

*NB - Business Name is KOSI KITS Pty Ltd - Trading As SydneyHypno - Business Account - Commonwealth Bank

When Direct Deposit: