Clinical Supervisor Criteria Verification Form

This form is for counselling agencies only.

Please complete all sections of the form below when submitting an agency application. Please note that by submitting this form, you are hereby affirming that the information that you provided is true and accurate.

For inquiries, please email the Counselling Internship Program Coordinator, mlaxamana [at] tyndale [dot] ca (subject: Clinical%20Counselling%20Internship%20Agency%20Application) (Michelle Laxamana) or contact by phone at 416.226.6620 ext 2139.

Supervisor Information

Full Name *

Phone *

Credentials *

Email *

Clinical Requirements

Do you meet CRPO’s “independent practice” requirement (completion of 1000 direct client contact hours and 150 hours of clinical supervision)? *

Yes

Please specify the number of years you have been practicing psychotherapy: *

Have you completed 30 hours of directed learning in providing clinical supervisor? *

Yes

If yes, please indicate your directed learning activities (e.g. course work, individual/peer/group learning, supervised practice as a clinical supervisor, independent study that included structured readings, etc.). *

Do you understand CRPO’s definitions of clinical supervision, clinical supervisor and the scope of practice of psychotherapy? *

Yes

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