List the name of the candidate applying for approval of the Supervision Agreement Form.
Supervision Agreement
In order to begin the accrual of supervised experience hours the Board must confirm the candidate for licensure has a completed application on file, a passing result on the jurisprudence exam, and a passing result on the national exam. In addition the candidate must also submit a W-4 confirming their status as an employee of the agency where they intend to accrue supervised experience and a completed Supervision Agreement.
Supervised experience may commence as of the approved date on the Supervision Agreement. Any hours accrued prior to the approval date on the Supervision Agreement will not be credited towards your supervised experience requirements and may result in the initiation of formal complaint procedures and/or loss of approved supervisor status.
You may submit your completed Supervision Agreement and W-4 in the Applicant Portal by logging into your portal account.
Form Instructions
Please Note: You must verify your employee status by submitting a W-4 for the location in which you are requesting to receive supervised experience hours, and the W-4 must be submitted with the Supervision Agreement Form.
Please refer below for hints on how to fill each of the form fields on the Supervised Agreement form.
List the location in which the candidate will be accruing supervised experience hours. You must have an approved supervision agreement for each location where the candidate is accruing hours.
List the address of the candidate's employing agency.
Provide the candidate's current phone # and email address.
Please provide the candidate's signature and the date signed.
List the name of the Board approved Supervisor applying to be approved to supervise the candidate. The Board approved supervisor is also commonly known as the Clinical Supervisor.
Select the check box that best describes the type of supervision the Board Approved Supervisor will be providing. Please note: Primary, Secondary, Back-Up, and Alternate Supervisors are industry terms and are not reflected in the Oklahoma Administrative Code (OAC) and have no bearing on the approval or disapproval of a Supervision Agreement Form.
List the address of the Board Approved Supervisor's employing agency.
Provide the Board Approved Supervisor's current phone # and email address.
Please provide the Supervisor's signature and the date signed.
List the name of the qualifying On-Site Supervisor. If the Board Approved Supervisor intends to act as the Board Approved Supervisor and the On-Site Supervisor, the Board Approved Supervisor will still need to complete the On-Site Supervisor information requested on the Supervision Agreement Form.
An On-Site Supervisor is a person who may not be an approved LPC, LMFT, or LBP supervisor but is licensed by the state of Oklahoma as a Licensed Marital and Family Therapist, Licensed Professional Counselor, Licensed Behavioral Practitioner, Psychologist, Clinical Social Worker, Psychiatrist, or Licensed Alcohol and Drug Counselor employed by the agency employing the Candidate whose assigned job duties include acting as the immediate supervisor to the Candidate and who is available to the candidate at all times when counseling services are being rendered by the Candidate.
List the On-Site License Type, License #, and Expiration Date of the qualifying license.
Please provide the On-Site Supervisor's signature and the date signed.
Check "yes" if you are requesting the use of technology-assisted supervision. Check "no" if you are not requesting the use of technology-assisted supervision.
Technology-Assisted Supervision as supervision that occurs through video teleconferencing, over secure internet connections, wherein a Board Approved Supervisor and a Candidate are in separate physical locations.
Technology-assisted supervision must be approved by the Board prior to the accrual of hours.
If requesting the use of technology-assisted supervision, please choose one the following factors:
- Distance between approved supervisor and candidate.
- Financial hardship on approved supervisor or candidate.
- Physical hardship on approved supervisor or candidate.
- Specialty credentials and other pertinent factors.
List the HIPAA compliant service that will be used to provide the technology-assisted supervision. Please note: Skype is not HIPAA compliant. Facetime may be altered to become HIPAA complaint, but is not HIPAA compliant at the factory settings. The Board's most common requested/approved HIPAA compliant services are V-See and Doxy.
Last Modified on
Dec 12, 2023
