Professional Disclosure Statement

A professional disclosure statement is required as part of the application process for the Approved Clinical Supervisor credential (ACS, 2000).

Professional Disclosure Statement (complete as if you were already licensed. All numbers 1-11 must be answered, using the headings below in PowerPoint format):

1. Name, title, business address, and business telephone number;
2. The listing of degrees, credentials, and licenses;
3. General areas of competence in a clinical mental health practice in which the applicant can supervise;
4. A statement documenting training in supervision and experience in providing supervision;
5. A general statement addressing model(s) of or approach to supervision, including the role of the supervisor, objectives and goals of supervision and modalities;
6. A description of the evaluation procedures to be used in the supervisory relationship;
7. A statement indicating the limits and score of confidentiality and privileged communication within the supervisory relationship;
8. A statement, when applicable, indicating the applicant is under supervision and that the supervisee’s actions may be discussed with the applicant’s supervisor;
9. A fee schedule (when applicable);
10. A way to reach the applicant in an emergency situation; and