Disclosure Statement for Clinical and Consulting Supervision
I appreciate your interest in choosing me as your clinical supervisor. This disclosure statement aims to inform you about my supervisory qualifications, offer an overview of the supervision process, and share essential administrative details.
I obtained my Master’s in Clinical Social Work from Florida International University (2013). You can find more information about my professional background at: http://www.linkedin.com/in/jerlinebaltimore/. I am a Licensed Clinical Social Worker in Florida (License No. SW15185).
I am an approved clinical supervisor certified by the Board of Clinical Social Work, Marriage & Family Therapy, and Mental Health Counseling and registered in Florida.
Clinical supervision is a process in which one individual facilitates another’s professional growth and therapeutic competence. My supervision approach utilizes three roles: teacher, psychotherapist, and consultant. I primarily assume the teacher and consultant roles, with the psychotherapist role reserved for situations where the supervisee’s thoughts, feelings, or behaviors hinder effective treatment. Please note that I cannot provide therapy; I may recommend you consult a therapist.
I am committed to providing the best supervision possible, with our relationship built on mutual respect and trust. My supervision adheres to the ethical standards of the National Association of Social Workers (NASW) and the Florida Board of Mental Health. While supervision focuses on your professional development, client care remains the top priority. Although I cannot guarantee specific outcomes regarding your learning objectives, I pledge to work with you toward the best possible results.
As a supervisee, you maintain control over our relationship and may terminate supervision anytime, with my support.
If you are counting these clinical supervision hours towards your professional license, you must keep track of the required individual or group hours.
You may ask me to share information with others, which I will do after receiving your signed release statement.
Fees: My fees range from $50-200 per hour, payable at the start of each session. Please note that fees are subject to change with 30 days’ notice. I accept cash, checks, and credit cards. Receipts will be issued upon booking by our third-party vendor, Stripe. Please retain these receipts for your records.
I empathize with those who may face financial challenges in affording supervision. However, I encourage you to consider this investment a vital step in your professional career. My commitment is to support your growth and development in the best possible way, ensuring that your investment in supervision pays off in the long run.
Cancellations: If you need to cancel an appointment, you must reschedule for the same week or be charged the fee.
Contact Information: My office hours are Monday through Friday, 9 am – 5 pm. To reach me, please email firstname.lastname@example.org.
Important Confidentiality Limitations: All information shared with me about your clients or yourself, including any records I maintain, will be confidential and not disclosed to others without your written consent. However, there are several critical exceptions regarding the release of confidential information. We are both legally obligated to break confidentiality under the following circumstances:
- Threats of self-harm or harm to others
- Reasonable suspicion of child, elder, or incapacitated person abuse
- Court or national security agency orders
- Defending against legal action or formal complaint before a court or regulatory board
- Your signed request for me to provide information to others