Clinical Supervision Form
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Supervision
Hour Minutes
AM
PM
AM/PM Option
Supervisor Name
First Name
Last Name
Case Manager Name
First Name
Last Name
Was the employee present and on time for all shifts/appointments?
Yes
No
Were there any incidents involving the employee? If yes, please describe in additional Comments below.
Yes
No
Do you communicate with peer coaches on an appropriate basis?
Yes
No
Are you handling documentation in an appropriate manner? (Documenting assessments, document phone calls to peers, etc)
Yes
No
Do you have any concerns related to peer coaches?
How many assessments did you schedule this week?
How many assessments did you complete this week?
Supervisor's recommendation to Case Manager.
Rate the quality of work of the Case Manager (1-10, 1-Unsatisfactory/10-Exceeds Expectations)
Employee Comments:
Type of Supervision performed
Please Select
Phone
Face to Face
Group
Additional Comments:
Submit
Should be Empty: