Supervisory Contract and Informed Consent Agreement

This agreement is between Daniel Trussell, Ph.D., MBA, LPC, NCC, CPCS and


and consists of the entire agreement between the parties in this contract.

This contract is entered into voluntarily by the parties for the purpose of clinical Supervision, typically leading toward completion of requirements for independent licensure as a Professional Counselor, Clinical Social Worker or Marriage and Family Therapist in Georgia, USA.

Rights and Responsibilities of the Supervisor and Supervisee

Each party to this contract assumes certain rights and responsibilities.

As the clinical Supervisor, Dr. Trussell agrees to

  1. Oversee your practice
  2. Build a working relationship with you
  3. Attend the Supervision meeting we agree to
  4. Assist you in determining your work goals
  5. Challenge your approaches and techniques and  support  your acquisition of new skills
  6. Help you help your clients via resource linkage, intervention strategies and the elimination of  therapy interfering behaviors on the part of the Supervisee
  7. Uphold the ethical and best practice standards of the industry

As the Supervisee, you agree to

  1. Uphold ethical guidelines, legal requirements  and professional standards
  2. Build a working relationship with Dr. Trussell
  3. Attend the Supervision meetings we agree to
  4. Help Dr. Trussell understand your work goals, strengths and deficiencies
  5. Remain open to alternative methods of practice
  6. Complete assignments and work tasks you agree to
  7. Express your thoughts and feelings about Supervision
  8. Never withhold information that could harm a client

You may perform counseling services in a variety of work settings. You must get written permission from your employer for me to supervise you and to have access to your clinical records for review. You must also get permission for me to visit your work site from time to time and to directly and indirectly observe your counseling sessions. In the event I directly observe or co-facilitate a counseling session you must not only get approval from your administrative Supervisor in writing, you must also get written permission from the client in advance to direct observation or co-facilitation. You will be provided a form for your client and for your administrative Supervisor to complete and sign before we begin Supervision.

You must inform your clients that you are in Supervision, under my license, and obtain their written informed consent for us to discuss and review their case.

Scope of Practice

Your scope of practice, the procedures, actions and processes within your practice, is limited to professional counseling services for which you are qualified by training and experience to perform. My scope of practice is overseeing your counseling activities. At no time will I directly counsel one of your clients, the only exception is an agreed upon co-facilitation for training purposes, which the client specifically agrees to.   Although I am legally and ethically responsible for all the clients you see, in the event a client must be referred from your practice, you are responsible for making that referral to a clinician with the skills and abilities to better assist that client.

Counselor of Record

It is understood that while under Supervision with Dr Trussell, clients seen by the Supervisee are under the care of Dr. Trussell and that both parties are responsible for the welfare of the clients being seen by the Supervisee. This relationship must be disclosed to clients in writing and include the client signature stating that they understand the Supervisor/Supervisee relationship and the obligations of each party.


The exploration of personal factors and therapy interfering behaviors are a natural part of the Supervision process.  However, the Supervisor and Supervisee will remain diligent in refusing to enter into dual relationships and to respect the Supervisor-Supervisee-Client relationship. Supervision is not to be confused with personal counseling although some coaching can be expected and is essential to a healthy Supervisor-Supervisee relationship. A Supervisee’s counseling relationship with a helping professional will not be a focus in Supervision beyond the sharing of insight or self-awareness and how that directly relates to the professional growth of the Supervisee. The Supervisor will not enter into a professional counseling relationship with a Supervisee.

Learning Activities

We will use a variety of activities during Supervision including the review of video and audio tapes, direct and indirect observation, role playing, didactic presentation of new skills, identifying therapy interfering behaviors and cultural influences, case and documentation review and self-awareness activities. You may also be invited to participate in small group Supervision activities.

Ethical and Legal parameters

You consent to entering into a Supervisory relationship with me and understand the risks and benefits.  You can expect to increase your skills and expertise in professional counseling and to learn to practice lawfully and ethically. You will gain insight into professional practice by drawing on my considerable experience and expertise. You have access to a resource to work effectively with your more challenging and difficult cases.  You are allowed to practice professional counseling under my license, as long as you perform professionally, lawfully and ethically.

If you are not able to practice successfully, it is unethical for me to recommend you for independent licensure. If you engage in unlawful or unethical activities, I must report such activities to the appropriate agency, as is appropriate to the situation or required by State Statute.

By entering into this contract, you attest you have read and agree to abide by the National Board of Certified Counselors Code of Ethics and the Georgia Composite Board of Professional Counselor, Social Worker and Marriage and Family Therapist Code of Ethics –Ga Code 135-7. As a Certified Professional Counselor Supervisor, I additionally agree to abide by the Licensed Professional Counselor Association of Georgia CPCS Code of Ethics and the American Counselor Association ACES Code of Ethics.

Recommendation for Independent Licensure

Satisfactory completion of Supervision hours with Dr. Trussell does not guarantee independent licensure.  Dr Trussell acknowledges that in rare cases, he may be ethically bound to withhold recommendation for independent licensure based on the outcomes of clinical Supervision and the professional maturity, emotional stability and skills level of the Supervisee.

At monthly intervals, the Supervisee will be informed of progress and of any barriers that would lead to withholding recommendation for licensure. In the event such deficiencies would preclude the recommendation of the clinical Supervisor, an action plan will be mutually created to overcome those deficiencies, along with measurable goals and objectives.  Supervisee will have a reasonable time to correct deficiencies with a formal timetable for successful completion of corrective action.

Performance expectations

You will gain specific knowledge and skills in a variety of theoretical orientations including evidence based practices such as CBT, DBT, PP, brief psychodynamic therapy, interpersonal therapy, systemic family therapy, mindfulness training, clinical hypnosis, narrative therapy, motivational interviewing and other orientations that I have advanced knowledge and training in.  Depending on the specific work goals we agree to, you can expect to advance your skill level in multiple orientations as well as determine when each orientation is a better fit for the needs of the client.

In addition to honing your skills, you will apply critical thinking to address ethical and cultural values necessary to conduct professional counseling.

We will review your clinical documentation to ensure that it meets best practice guidelines. This includes your statement of understanding for clients, face sheets, bio- psycho-social assessments, treatment plans, progress notes, termination summaries and other documentation.



Evaluation and Feedback

While immediate feedback and cross feedback is enormously helpful in Supervision, there are two evaluative processes we will utilize. This includes both formative evaluations and summary evaluations.

Formative evaluation

At the end of each session, we will summarize the contents of the Supervision session and formulate short term, intermediate and long terms goals to work toward. You will be given specific feedback at the end of each session that includes impressions regarding incremental progress or lack thereof.  We will agree upon assignments you will work on before the next Supervision session.

Summary evaluation

Every 90 days, we will convene a meeting that formally evaluates your progress and addresses any corrective actions you have undertaken.  At this quarterly meeting, you will also formally evaluate my Supervision of your practice and help me understand what has been most helpful and least helpful in your development as a professional counselor.  The summary evaluation includes a written report that you will sign acknowledging the evaluation. This evaluation will be placed in your Record of Supervision. You will have an opportunity to add your comments to this evaluation in the self -evaluation component of the document.

The Quarterly Supervisor Summary Report includes a brief narrative and a rating form.

The narrative includes an evaluation of

  1. Strengths
  2. Areas of growth
  3. Critique of a complete session review
  4. Review of clinical issues, range of clients seen and orientations/techniques utilized

The Rating Form includes a Likert Scale rating in the following areas

  1. Client relationship building
  2. Multicultural and advocacy competences
  3. Professionalism
    1. Counselor performance skills
    2. Counseling cognitive complexity  skills
    3. Case conceptualization
    4. Self awareness
    5. Professional behaviors
  4. Mastery of learning goals


Cost of Supervision

Supervision is a fee for service activity. You will pay, at time of service,   $_______ per one hour of Individual Supervision.  Additional fees may apply for group supervision, training webinars and seminars or complex telephone consultations between Supervision sessions.


Termination of Supervisor/Supervisee Relationship

This contract shall remain valid for 12 months from the date it is signed.  In the event either party determines that this Supervision is not a “good fit”, the Supervisory relationship will be terminated 30 days from written notice. Should either party revoke this contract, Supervisee will be required to provide the name of the new Clinical Supervisor for the purposes of transferring caseload. Supervisee agrees not to continue seeing clients until such time as a new Supervisor has contracted with Supervisee to assume the Supervisor role. If the Supervisee is not licensed to practice independently in Georgia and fails to contract with a new Clinical Supervisor within the 30 day termination period, a notice will be sent to the Georgia PC/SW/ MFT Licensing Board apprising the Board that the Supervisee is unlawfully practicing in the State of Georgia.




Daniel Trussell, Ph.D., MBA, LPC, NCC, CPCS

Date __________________________





Date ___________________________