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Supervision Agreement/Verification of Experience Form

Below is a link to the Board's Supervision Agreement and Verification of Experience Form.

The concept of the Supervision Agreement will help to facilitate communication between supervisors and trainees making for a well thought out course of training and thereby a higher quality supervised professional experience.

Effective January 1, 2005, this agreement or its equivalent must be completed and signed by the supervisor and trainee prior to accruing supervised professional experience. If the commencement of supervised professional experience occurred prior to January 1, 2005, the completion of the Supervision Agreement is still required for any hours that were accrued after January 1, 2005.

Except for Psychological Assistant in private practice settings, once the supervised professional experience has been completed, the Verification of Experience Form must be completed and signed by the primary supervisor or, if the experience is part of a formal internship, completed and signed by the Director of Training and submitted with the Supervision Agreement Form directly to the Board by the primary supervisor or Director of Training. DO NOT SEND IN THE AGREEMENT FORM UNTIL THE SUPERVISED PROFESSIONAL EXPERIENCE HAS BEEN COMPLETED AND THE VERIFICATION OF EXPERIENCE FORM HAS BEEN COMPLETED.

If any hours of supervised professional experience were accrued prior to January 1, 2005, or if the hours were accrued outside of California, click here for the two-page verification of experience form that must be used.

The Board has the authority to deny any hours of supervised professional experience in which a Supervision Agreement was not properly completed prior to the accrual of hours after January 1, 2005.

The Board appreciates any feedback or comments regarding the new forms. Please e-mail any comments or suggestions to boplicensing@dca.ca.gov.