Clinical Supervision Worksheet

Instructions: Complete the following table as part of clinical supervision sessions. Table 1 is the sample Table. Supervisors can make their own customized Monthly Plan with the help of Table 2-5.

Table 1 (Sample Table)

Learning goals for this month

Type, level, or degree of knowledge

Weekly division

Curriculum content

Performance of the supervisee for each lesson

Outcomes achieved

Sample

(E.g. Ethical Principles in Therapy)

Factual

Conceptual

procedural

Week 1

E.g. APA’s guidelines for ethical practice

Case Examples

Role Plays

Ethical Dilemmas

Need

Improvement

Satisfactory

Excellent

Comprehension and application of APA’s ethical principles is achieved.

Table 2

Learning goals for this month

Type, level, or degree of knowledge

Weekly division

Curriculum content

Performance of the supervisee for each lesson

Outcomes achieved

Lesson 1

Need

Improvement

Satisfactory

Excellent

Table 3

Learning goals for this month

Type, level, or degree of knowledge

Weekly division

Curriculum content

Rate the performance of the supervisee for each lesson

Outcomes achieved

Lesson 2

Need

Improvement

Satisfactory

Excellent

Table 4

Learning goals for this month

Type, level, or degree of knowledge

Weekly division

Curriculum content

Rate the performance of the supervisee for each lesson

Outcomes achieved

Lesson 3

Need

Improvement

Satisfactory

Excellent

Table 5

Learning goals for this month

Type, level, or degree of knowledge

Weekly division

Curriculum content

Rate the performance of the supervisee for each lesson

Outcomes achieved

Lesson 4

Need

Improvement

Satisfactory

Excellent

Other details: Fill in the details below, and give signatures:

Venue of the sessions: _____________________

Frequency of the sessions: (e.g. Weekly):_____________________

Monthly review date: __________________________________

What to do in case of appointment cancellation: ________________________

Signature of Supervisor: _________________

Signature of supervisee:__________________

Reference:

Walden, Patrick & Gordon Pershey, Monica. (2013). Applying Adult Experiential Learning Theory to Clinical Supervision: A Practical Guide for Supervisors and Supervisees. Perspectives on Administration and Supervision. 23. 122-144. 10.1044/aas23.3.121.

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Please note: There may be a more up-to-date and editable version of this worksheet available here which may be more suitable to present to clients if you are a therapist or to use in a classroom as a teacher or guidance counsellor.