Evaluation of Supervised Experience:

Submission to the Board:

Please note: The Board has transitioned to a new operating system. However, not all records could be migrated to the new operating system. Please read carefully the instructions below to determine how to submit your evaluation of supervised experience to the Board.

1. If your supervision agreement was submitted and approved through the portal, then you will submit your evaluation of supervised experience through the portal as well. 
2. If your supervision agreement was not submitted and approved through the protal, then you will continue to use the PDF version of the evaluation of supervised experience to the Board for review.

You may download the PDF Evaluation of Supervised Experience at the following link:   

Evaluation of Supervised Experience - LPC

Send your completed form to: Info.BehavioralHealth@bbhl.ok.gov

Name of Supervisee: List the name of the supervisee reporting supervised experience.

Supervisor: List the name of the Board Approved LPC Supervisor for the supervisee reporting supervised experience.

Is the Board Approved LPC Supervisor also acting as the Board Approved On-Site Supervisor? Check "yes" if the Board Approved LPC Supervisor is also acting as the Board Approved On-site Supervisor. Check "no" if the Board Approved LPC Supervisor is not also acting as the Board Approved On-site Supervisor.

If the Board Approved LPC Supervisor is also acting as the Board Approved On-Site Supervisor then you do not need to include any dates in the "Date of Supervisor Consult w/ On-Site" column.

Name of Candidate's Employing Agency: The name of the candidate's employing agency must correspond to one of the locations listed as the candidate's employing agency on the Board approved supervision agreement. If the supervisee has been approved and provided services at more than one Board approved location you may list each location in this field.

Was 100% of experience listed below accrued in accordance with OAC §59-1902 (3)(4)(5)(6)(7)?: OAC §59-1902 (3)(4)(5)(6)(7) defines counseling, counseling treatment interventions, consulting, referral activities and research activities. In accordance with OAC 86:10-11-3(a), in order to qualify as supervised experience the counseling activities reported on the evaluation must meet one of these definitions. Please mark "yes" if all activities meet the definitions outlined in the OAC. If not, then mark "no", and no credit will be awarded for the hours reported. 

The acceptability of research activities is further defined in OAC 86:10-3-2(e)

On a scale of 1-5, please provide the supervisor's rating of the supervisee's professional activity: On a scale of 1 to 5, 1 being the lowest score and 5 being the highest score please rate the supervisee's professional activities for the weeks documented on the supervised experience log. This portion should be completed by the LPC approved supervisor.

Work Week Beginning Date: The work week beginning date may initially be any day of the week. However, once the initial work week date has been documented, each additional week should begin on the same day of the week. (Ex. Week one starts on a Monday, week two should also start on a Monday.)

Date(s) met with Supervisor: Each week the supervisee is required to meet with the LPC approved supervisor. Please use the "Date(s) met with Supervisor" column to document the date the supervisee met with the LPC approved supervisor. If the supervisee did not meet with the supervisor, they will not receive credit for that week. This is a weekly requirement and meeting with the LPC approved supervisor cannot be "made up" during any subsequent weeks.

Dates of Observation (Live or Taped): During each 6 month evaluation period the supervisee must be observed providing counseling services, either taped or in person, by the LPC approved supervisor two times. Please use the "Dates of Observations" column to document the dates the observations were completed. The supervisor may observe twice on the same day. Because only two observations are required many of the fields in this column may be blank. However, you may use the available fields to document any additional observation dates.

Date of Supervisor Consult w/ On-Site: During each 6 month evaluation period the LPC approved supervisor must consult with the Board approved On-site Supervisor one time. Please use the "Date of Supervisor Consult w/ Onsite Supervisor" column to document the date the consultation was completed. Because only one consultation is required many of the fields in this column may be blank. However, you may use the available fields to document any additional consultation dates.

If the Board Approved LPC Supervisor is also acting as the Board Approved On-Site Supervisor then you do not need to include any dates in the "Date of Supervisor Consult w/ On-Site" column.

Total Face-to-Face Supervision Hours, GRP & IND: Use the "Total Face-to-Face Supervision Hours" columns to document the total group supervision and the total individual supervision hours.

Total Direct Client Contact Hours: Use the "Total Direct Client Contact Hours" column to document the total direct client contact hours. Direct client contact supervised experience is defined by the number of hours the supervisee spends directly counseling their clients.

Total Supervised Experience Hours: Use the "Total Supervised Experience Hours" column to document the total supervised experience hours. The total supervised experience consists of the face-to-face supervision hours, direct client contact hours, and additional hours that were accrued in accordance with OAC §59-1902 (3)(4)(5)(6)(7).

Candidate Signature: The supervisee must sign each evaluation. By signing the evaluation the supervisee is acknowledging the information documented on the evaluation is a true and accurate representation of their counseling activity and the hours they have documented.

Supervisor(s) Signature(s):  The LPC approved supervisor must sign each evaluation. By signing the evaluation the LPC approved supervisor is acknowledging the information documented on the evaluation is a true and accurate representation of the supervisee's counseling activity and the hours they have documented. If more than one LPC approved supervisor documented hours or observation on the form then they may also sign the supervisor signature line on page one.

Additional Signature(s): If more than one LPC approved supervisor documented hours or observation on the form then they may also sign the supervisor signature line, and they may also use the additional lines provided on page two. However, if no additional signatures are required then the signature lines may be left blank. If no additional signatures are required and there are no LPC approved supervisor comments to submit then page two is not required.

Additional Supervisor Comments: Submitting supervisor comments is optional. However the LPC approved supervisor may use the space provided to document any information regarding the supervisee they feel is relevant to the fitness review of the supervisee. If no additional signatures are required and there are no LPC approved supervisor comments to submit then page two is not required.

Timely Submission:

The Oklahoma Administrative Code (OAC) requires the Evaluation of Supervised Experience forms be submitted semi-annually, 86:10-11-6. Documentation of supervised experience (b)

"The supervisor and supervisee shall sign and submit the "Evaluation of Supervised Experience," including documentation of observations and date of consultation between approved supervisor and on-site supervisor, semi-annually. "

The Board is empowered to interpret the rules, and they have long held that the Evaluation of Supervised Experience forms must be submitted semi-annually, semi-annually to be defined as every six (6) months.

In accordance with OAC 86:10-11-6(e) any Evaluation of Supervised Experience form submitted beyond 60 days of the semi-annual due date will not be credited towards the duration of supervision as described in 86:10-11-5.