Supervision Registry


First Name:

Middle Name/Initial:

Last Name:





Daytime Phone:




Please check all that apply and indicate related field for each degree:

Area of Specialization:

Area of Specialization:

Area of Specialization:

Area of Specialization:

Issue Date:
Expiration Date:

Issue Date:
Expiration Date:

Other License/Certification Type:
Number: Issue Date: Expiration Date:

Other License/Certification Type:
Number: Issue Date: Expiration Date:

Other License/Certification Type:
Number: Issue Date: Expiration Date:

Counseling Competencies/Specialty Areas of Practice:

Creative/expressive arts
Play therapy
Women's Issues
Men's Issues
Substance abuse
Christian Counseling
Traumatic Stress/PTSD
School counseling
Assessment of normal/abnormal behavior
Child and Adolescent Counseling



As defined by PA Code 49 of the PA State Board of Social Workers, Marriage and Family Therapists and Professional Counselors, I submit by my signature below that:

1. I qualify as a supervisor per § 49.3,

§ 49.3. Qualifications for supervisors

To qualify as a supervisor, an individual shall meet one of the following criteria:

(1) Holds a license as a professional counselor and has 5 years experience within the last 10 years as a professional counselor.

(2) Holds a license, has at least a master's degree in a related field and has 5 years experience within the last 10 years in that field.

2. I have read and understand § 49.14 Standards for Supervisors below,

  1. I have read and understand the Verification of Supervised Clinical Experience forms, scroll down to page 4, which must be signed by me and submitted by the supervisee as part of her/his Application for a License by Examination to Practice Professional Counseling.
  2. I have a copy of my Professional Counseling Disclosure Statement or Counseling Supervisory Disclosure Statement available upon request.
  3. I understand that I must contact PCA to update my Supervisor Profile if there are substantive changes, including education/degrees, certification/licenses, competency areas, contact information, etc.

§ 49.14 Standards for supervisors

Supervisors, and those to whom supervisory responsibilities are delegated under § 49.13(a)(4) (relating to licensed professional counselors) shall comply with this section. Supervisors will be asked to attest to compliance on the verification of experience form, which shall accompany the supervisee's application for licensure. The Board reserves the right to require a supervisor by documentation or otherwise to establish to the Board's satisfaction that compliance occurred.

(1) The supervisor shall be qualified by training and experience to practice in the supervisee's areas of supervised practice.

(2) The supervisor may not be a relative of the supervisee by blood or marriage, may not be involved in a dual relationship which obliges the supervisor to the supervisee and may not engage in treatment of the supervisee.

(3) An individual whose license has been actively suspended or revoked by a licensing Board will not qualify as a supervisor.

(i) If during the period of supervision, the supervisor's license is suspended or revoked, the supervisor shall immediately notify the supervisee and immediately cease supervision. Credit will be given for hours completed prior to the disciplinary action.

(ii) The supervisee shall obtain a new supervisor to complete the required experience.

(4) The supervisor shall be responsible for ensuring that the requirements of § 49.13(b) are met.

(5) The supervisor shall be accessible to the supervisee for consultation.

(6) The supervisor shall be empowered to recommend the interruption or termination of the supervisee's activities in providing services to a client/patient and, if necessary, to terminate the supervisory relationship. Hours accumulated for activities not approved by the supervisor will not count towards satisfying the 3,600 hours of supervised experience.

(7) The supervisor shall ensure that the supervisee's status as a supervisee is made known to the supervisee's patients, and also ensure that the supervisee has obtained written permission from each patient to discuss his case with the supervisor.

(8) The supervisor shall establish objectives to be achieved by the supervisee during supervision.

(9) The supervisor shall review issues of practice and ethics with the supervisee.

(10) The supervisor shall maintain notes or records of scheduled supervisory sessions and provide these records to the Board upon request.

(11) The supervisor shall observe client/patient sessions of the supervisee or review recordings of these sessions.

(12) In supervisory meetings, the supervisor shall discuss the supervisee's level of work–for example, the supervisee's areas of competence and areas of needed improvement.

(13) The supervisor shall provide the supervisee with recommendations bearing on further professional development, professional study and skills necessary for independent practice.

(14) The supervisor shall prepare written evaluations or reports of progress which shall delineate the supervisee's strengths and weaknesses. These evaluations or reports shall be discussed with the supervisee on at least a quarterly basis.

(15) The supervisor shall encourage the supervisee to work with professionals in other disciplines as indicated by the needs of each client/patient and shall periodically observe these cooperative encounters.

(16) The supervisor shall encourage the supervisee to access multidisciplinary consultation, as necessary.

Rev. 07/09