Supervision Intake Form

Supervisee Information

First Name
Last Name
Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Email Address

Supervisor Information

First Name
Last Name
Phone Number
Email Address

Additional Information

How did you hear about Shine Bright?
Is there any other information that would be helpful at this time?

Shine Bright is committed to providing quality care. Please read the following information explaining confidentiality, policies, and procedures. By signing below, you acknowledge that you have read and understood the confidentiality and privacy information and consent to begin supervision.

The purpose of supervision is to assure the supervisee’s professional development and fulfill requirements for licensed clinical social worker supervision through the Texas Board of Social Worker Examiners. Both supervisor and supervisee will comply with all laws and regulations regarding supervision and adhere to the NASW Code of Ethics. Supervision may take place in both face-to-face and telecommunication settings.

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Shine Bright Counseling Required Forms

Please review the following forms before completing this intake:

Open Shine Bright Counseling Required Forms

Please confirm that you have read and agree to the following:

Consent to Treatment and Confidentiality formComplaint Process formTelemental Health Informed Consent formNotice of HIPAA Privacy Policies formConsumer Consent Disclosure form

Electronic Signature (Acknowledgment Required)
I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law.

Submit Supervision Intake Form