Group Supervision Disclosure Statement

Texas State University

Counseling Center

Group Supervision Disclosure Statement

The Texas State University Counseling Center is a training site for masters and doctoral graduate trainees as well as postdoctoral level clinicians.  Doctoral level clinicians are enrolled in the Counseling Center’s doctoral internship in health service psychology which is accredited by the American Psychological Association.

Your group leader is a trainee and is being supervised by a licensed clinician.  During your first meeting with the group leader, the name and contact information of the supervisor will be provided.  Your group leader’s supervisor has full responsibility for the work of the trainee.  Your group leader will meet with their supervisor on a regular basis to discuss the details of their work in group.  Confidentiality, and the limits thereof, apply to both group leaders and supervisors.

If you have any questions about this supervisory relationship, we encourage you to speak to your group leader(s).  Questions may also be directed to the Director of Training, Dr. Clare Duffy, at 512-245-2208.

Signing this form acknowledges your informed consent for treatment by a clinician under supervision. This form will become part of your clinical record.

Enter your TXST ID number (A0…):______________________________

Printed first and last name:  _____________________________________________________

Signature ________________________________   Date Authorized _____________________