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Supervision Disclosure Statement Michael Athanasios, MA, LPC, NCC, ACS Office: 8567454593 Fax: 8564947878 This document is designed to inform you, the supervised, of my educational and professional

How to fill out supervision disclosure statement

How to fill out a supervision disclosure statement:

1. Begin by gathering all the necessary information and documents required for the supervision disclosure statement. This may include your personal identifying information, contact details, and any information specific to the supervisory relationship.
2. Fill out the header section of the form, which typically includes fields such as your name, address, phone number, and email. Make sure to provide accurate and up-to-date information.
3. Proceed to the section that requires you to disclose any previous or current supervisory relationships. This may involve providing details such as the name of the supervisor, their contact information, the start and end dates of the supervision, and any relevant credentials.
4. If you have had multiple supervisory relationships, repeat step 3 for each one, ensuring that you provide complete and accurate information for each instance.
5. In the following section, you might be asked to detail the frequency and duration of the supervision you received, as well as any specific methods or modalities utilized during the supervision process.
6. Some supervision disclosure statements may also require you to disclose any complaints or disciplinary actions that have been taken against you as a supervisee. If applicable, provide the required information truthfully and comprehensively.
7. Finally, review the completed supervision disclosure statement for any errors or omissions. Make sure all the information provided is accurate and complete before signing and dating the form.

Who needs a supervision disclosure statement:

1. Individuals pursuing professional licensure: Many licensing boards and regulatory bodies require individuals in certain professions (such as counselors, therapists, social workers, etc.) to complete a supervision disclosure statement as part of the licensure process.
2. Supervisors: In some cases, supervisors may also be required to complete a supervision disclosure statement, particularly if they are overseeing the clinical or professional development of supervisees.
3. Organizations or institutions: Certain organizations or institutions may also require individuals under their employment or affiliation to complete a supervision disclosure statement, especially if they work in regulated fields where supervision is a crucial component.

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What is supervision disclosure statement?

The supervision disclosure statement is a document required to be filed by certain individuals or entities who are under the supervision of a regulatory authority.

Who is required to file supervision disclosure statement?

Individuals or entities who are under the supervision of a regulatory authority are required to file a supervision disclosure statement.

How to fill out supervision disclosure statement?

The supervision disclosure statement is typically filled out by providing detailed information about the individual or entity under supervision, including their activities, compliance measures, and any other relevant information.

What is the purpose of supervision disclosure statement?

The purpose of the supervision disclosure statement is to provide transparency and accountability for individuals or entities under regulatory supervision.

What information must be reported on supervision disclosure statement?

The supervision disclosure statement typically requires information such as financial activities, compliance measures, organizational structure, and any other relevant information deemed necessary by the regulatory authority.