Supervision Preparation Form: Individual (psychotherapy, coaching, counselling, etc)

To save time, please complete as much as possible/relevant of this form and submit it to Julie before the start of the session. As you type the boxes will stretch to suit. Once items have been completed you need only re-submit parts if/when they need updating. If the basic information is unchanged, you can just submit revised sections about the supervision you want. The supervision request has been formatted to be a separate page – you can delete the previous pages if the details are the same as you have already submitted.

Your name:
Client name (use only first name or pseudonym for confidentiality):
Cultural background if different to the practitioner:
Gender/sexual orientation (if adult): / Age
How client contact was initiated e.g. direct contact with you, via a centre, referred (by whom/what role)
Presenting problem, and was this presented to you by the client or via a third party (e.g. parent, partner, legal requirement, HR, manager, teacher, etc)
Environment -family, organisational, school, – whichever is/are relevant as examples below
Family – parents, siblings, children, partner, etc - ages, living/dead/elsewhere etc; whether still in contact, client description of relationships
Or organisational contacts – manager, colleagues, subordinates, etc, client description of relationships
Or other environment e.g. school – teachers, friends, other school employees, etc, client description of relationships
Medical information – physical and mental e.g. ailments and whether self or professional diagnosis; mental health issues and whether self or professional diagnosis
Medication – names, dosages, purposes
Other relevant factors, such as addictions, eating problems, physical disabilities, etc
Are you able to be in contact with the general practitioner, psychologist, psychiatrist, etc?
TA Diagnosis and Evidence you have used (e.g. behaviour, appearance, content, etc)
ego states observed
structural/internal ego states
transactions
life position(s)
drivers
injunctions
attributions
process script
script story
doors to contact
other TA concepts considered – state which
Contracting – bilateral or multi-party contract, who are the stakeholders (e.g. client, organisation, centre, school, HR, manager, parent, etc) - who is or will be involved and how
Contracting- your expectation of what the contract might become or, if already agreed with client and/or any stakeholders, what does the contract comprise:
At the procedural/practical level
At the professional level
At the psychological level – and how much of that have you brought to the attention of the client, or how much are you planning to bring to the attention of the client or your rationale for why the client should not be made aware of any of the psychological level at the current stage of the working alliance
Are there any considerations at other levels, such as perceptual, political, etc?
Interventions/Treatment plan - how have you framed your ideas about the overall interventions/treatment plan:
In the short-term (how long or for how many sessions) – what do you anticipate?
In the medium-term (how long or how many sessions) - what do you anticipate?
In the longer term (how long or how many sessions) – what do you anticipate?
Date form completed/updated to this part
Please provide your name and the name of the client on this page for reference purposes:
Supervisee: / Client:
What is your supervision question or supervision topic?
What result do you think is realistic for you to arrive at during the time allotted to the supervision session? (e.g. review of your diagnosis, analysis of specific segments of your process with the client, identifications of patterns of interaction with the client, review of progress, identification of (at least 3) potential options for you with this client, etc)
What relationship between you and the supervisor do you anticipate will be the most appropriate?
How do you describe the way in which responsibility will be shared between supervisor and supervisee?
Date of planned supervision:
There is no need to send the previous pages again if you have submitted them for an earlier supervision, unless you have amended/updated them - please type YES or NO in this box to confirm whether updated information is being provided

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