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Professional Disclosure Statement Clinical Supervision. Keith Mobley, PhD, PCs, NCC, ACS3363345215 (office)Dept of Counseling and Educational Development3364301518 (cell)220 Ferguson Buildingk_mobley@uncg.eduGreensboro, NC 27402Educational Background and CredentialsPhDCounseling and Counseling Education Counseling and GuidanceBSBiologyLicensed Professional Counselor Supervisor (North Carolina)Approved Clinical SupervisorNational Certified Counselor.
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How to fill out supervision disclosure statementdoc
How to fill out supervision disclosure statementdoc
01
Begin by providing your personal information such as your name, address, and contact details.
02
Fill in the details of your supervising agent or agency, including their contact information.
03
Specify the dates of supervision and the nature of the relationship between you and your supervisor.
04
Include any relevant disclosures or conflicts of interest that may affect your supervision.
05
Sign and date the form to acknowledge that the information provided is accurate.
Who needs supervision disclosure statementdoc?
01
Professionals in industries such as counseling, psychology, social work, and therapy who are required to undergo supervision as part of their licensing or certification process.
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What is supervision disclosure statementdoc?
The supervision disclosure statementdoc is a document that discloses information about the supervision of a specific activity or program.
Who is required to file supervision disclosure statementdoc?
Certain individuals or entities involved in supervising activities or programs are required to file the supervision disclosure statementdoc.
How to fill out supervision disclosure statementdoc?
The supervision disclosure statementdoc can be filled out by providing information about the supervision activities being conducted.
What is the purpose of supervision disclosure statementdoc?
The purpose of the supervision disclosure statementdoc is to provide transparency and accountability in the supervision of activities.
What information must be reported on supervision disclosure statementdoc?
The supervision disclosure statementdoc must report information about the supervision activities, the individuals or entities involved, and any relevant dates or deadlines.
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