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It provides application instructions and requirements for supervised practice toward licensure, including education prerequisites, supervision ratios, documentation rules, and enrollment proof. Part A collects supervisee information, supervision setting details, duties, dates, supervised hours, internship alignment, and license information plus certifications. Part B collects supervisor licensing details, competence areas, supervision nature, and confirmation of reviewed supervisee statements.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/professional-counselor-training-supervision-agreement/429813/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/professional-counselor-training-supervision-agreement/429813.png","ImageObject",300,407,{"name":92,"@type":93},"Asher","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-30","2026-09-29",true,{"@type":102,"interactionType":103,"userInteractionCount":52},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"When must the training supervision agreement form be filed?","Question",{"text":112,"@type":113},"It must be filed at the beginning of the training experience.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What are the supervision hour requirements during the training period?",{"text":117,"@type":113},"You must have one-hour face-to-face supervision for each 20 hours of work, and supervised experience must be documented according to the Board’s rule 4757-17-01.",{"name":119,"@type":110,"acceptedAnswer":120},"What information does Part B require from the training supervisor?",{"text":121,"@type":113},"Part B collects supervisor licensing status, license number and expiration date (if licensed), areas of professional competence, the nature of supervision, whether the supervisor’s practice includes diagnosis and treatment of mental and emotional disorders, and confirmation that the supervisor reviewed the supervisee’s statements.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},429813,1790995548,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":52,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":19,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":52,"preview_page_count":4},687197207639,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","STATE OF OHIO  \nCOUNSELOR AND SOCIAL WORKER BOARD  \n77 SOUTH HIGH STREET, 16TH  \nCOLUMBUS, OH 43266  \nPROFESSIONAL COUNSELOR  \nTRAINING SUPERVISION AGREEMENT  \nInstructions to applicant:  \n1. Make additional copies of this form in the event you have more than one supervisor during the supervised practice time required for licensure.  \n2. This form must be filed at the beginning of the training experience.  \n3. Individuals who are registering experience with the Ohio Counselor and Social Worker Board must have a master’s degree or [Ph.D. in](Ph.D. in) Counseling. Be certain your program meets this requirement as specified in board rule 4757-13-03. Degrees in psychology, social work and marriage and family therapy are not considered degrees in counseling.  \n4. Individuals must register practica and internships. Individuals with a master’s degree in counseling must have a total of two years (3000 hours) which must be post PC (Professional Counselor) . Individuals with a Doctorate must have two years of experience, one year (1500 hours) in an approved doctoral internship and one year (1500 hours) which must be competed after the degree is conferred.  \n5. During the training period, you must refer to yourself as a Counselor Trainee or Professional Counselor/Clinical Resident. You must hold a valid Professional Counselor License in order to use the PC/Clinical Resident title.  \n6. You must have one-hour face-to-face supervision for each 20 hours of work.  \n7. All supervised experience for licensure must be documented as specified in board rule 4757-17-01  \n8. Please attach proof of enrollment in a practicum or internship for approval.  \n9 LPC : PC 9 PCC  \nPART A:  To be completed by supervisee SS\\#   -   -    \n1. Name of Applicant   Daytime Phone   First Middle Last  \n2. Address   Number Street City State Zip  \n3. Name of Supervisor   Title    \n4. Address of Supervisor   Phone    \n5. Name, address and scope of practice of setting in which supervision is taking place:  \n6. Your supervisor’s area(s) of competence in counseling (please attach professional disclosure statement of supervisor):  \n\n| 7. | Describe the duties you plan to perform. (For Clinical Residents Per rule 4757-13-03 (a) a minimum of 50 percent of the work consists of face-to-face client contact involving the delivery of clinical counseling services, which includes the diagnosis and treatment of mental and emotional disorders) . |\n| --- | --- |\n\n8. Dates of supervision at this setting: From   to    \nmo/yr mo/yr  \nPlease supply estimated ending date. We no longer approve ongoing status.  \nTotal number of hours of supervised experience:  \nTotal Work Hours   (Maximum of 1500 hours in one year)  \n9. Is there any part of this supervision being done to meet the internship requirements of a doctoral program?  \n[ ] Yes [ ] No  \nIf yes, indicate the university   (please attach a copy of your student transcript verifying the actual beginning and ending of the semester/quarter.  \n10. Please list the license number, date of issuance and expiration dates if you are a PC.  \nPC/LIC \\# Issuance Date Expiration Date  \n11. Do you hold any other Licenses or certifications? [ ] Yes [ ] No  \nLIC/CERT \\# Issue Date Expiration Date  \nMemo of Understanding: I have read the counselor licensure law and understand the rules and regulations that pertain to Professional Counselor/Clinical Resident. I understand that I will have to submit the application and fees for the PCC after satisfactory completion of the supervision hours. I further understand that any person who knowingly makes a false statement on the registration form is guilty of falsification under section 2921.13 of the Ohio Revised Code, a misdemeanor of the first degree.  \nPart B:  To be completed by the Training Supervisor  \nInstructions to supervisor:  \nAfter completing this form, please return it to the supervisee who is responsible for sending it to the Board.  \n1. Are you a Licensed Professional Counselor or a Licensed Professi","cbCaihRReDCBMiWO","https://ap.wps.com/l/cbCaihRReDCBMiWO","pdf",45249,"English","# Instructions to applicant\n# Part A: To be completed by supervisee\n## Applicant and supervisor information\n## Supervision setting, duties, dates, and hours\n## Internship requirements and license information\n# Memo of Understanding\n# Part B: To be completed by the Training Supervisor\n## Supervisor licensing and competence\n## Nature and scope of supervision\n## Experience in training supervision\n## Final review and attachments","[{\"question\":\"When must the training supervision agreement form be filed?\",\"answer\":\"It must be filed at the beginning of the training experience.\"},{\"question\":\"What are the supervision hour requirements during the training period?\",\"answer\":\"You must have one-hour face-to-face supervision for each 20 hours of work, and supervised experience must be documented according to the Board’s rule 4757-17-01.\"},{\"question\":\"What information does Part B require from the training supervisor?\",\"answer\":\"Part B collects supervisor licensing status, license number and expiration date (if licensed), areas of professional competence, the nature of supervision, whether the supervisor’s practice includes diagnosis and treatment of mental and emotional disorders, and confirmation that the supervisor reviewed the supervisee’s statements.\"}]","Professional Counselor Training Supervision Agreement | PDF",1790651254]