PSYCHOTHERAPY SUPERVISION TALLY for ______(Name)

PSYCHOTHERAPY SUPERVISION TALLY FOR ______(Name)

# / Dates / Venue/Program / Mode
(Hours) / Supervisor’s Name, Qualifications and Contact Details / Generalist or Specialist Focus
Independent / Dyad / Group / Case Conferences
1
2
3
4
5
6
7
Total of Modes
Total Supervision Hours

Grandparenting Route Notes: Min 40 (with 20 of those Clinical) Maximum Countable Hours are 160 with Max 160 for Clinical Supervision and 80 other

Independent Practice for Grandparented Applicants: 150 hrs of Clinical Supervision

Regular Route Notes: 100 hrs of Clinical Supervision (50 in individual or dyad) (Balance: Group Max 8 participants)

For more details see http://www.crpo.ca/wp-content/uploads/2013/09/Scoring-of-Portfolio-Evidence-for-Grandparenting-Sept-513.pdf and http://www.crpo.ca/wp-content/uploads/2013/09/SUMMARY-TABLE-Registration-Reg-TC-Psychotherapists-Sept-513.pdf

Form designed by Trish McCracken CCPA Ontario Anglophone Director PAGE 1