Which states require a supervisor disclosure statement?

Several states require or strongly recommend supervisor disclosure statements, though the specific requirements and terminology vary. Oregon requires a Professional Disclosure Statement (PDS) from all licensed counselors and supervisors, to be provided before services begin. North Carolina's Board of Licensed Clinical Mental Health Counselors requires professional disclosure as part of the supervision process. Washington State's WAC 246-810-031 mandates disclosure of supervisory arrangements, confidentiality limits, and the type and duration of services. Maryland, Michigan, and Arizona also require supervisees to present clients with written documentation of their supervisee status, supervisor's identity, and the supervisory arrangement. Even in states without an explicit regulatory requirement, providing a supervisor disclosure statement is considered best practice by the APA and ACES.

Is the supervisor disclosure statement the same as the supervisee's disclosure to clients?

No, these are two different documents. The supervisor disclosure statement is provided by the supervisor to the supervisee at the beginning of the supervisory relationship. It informs the supervisee about the supervisor's qualifications, supervision approach, evaluation methods, confidentiality policies, and grievance procedures. The supervisee's disclosure to clients is a separate document — provided by the supervisee to each of their clients — informing clients that the therapist is working under supervision, naming the supervisor, and explaining how client information will be shared in supervision. Both are important, but they serve different purposes and are directed at different audiences.

When should the supervisor disclosure statement be provided?

The supervisor disclosure statement should be provided to the supervisee before the first supervision session, ideally at the same time the supervision contract is reviewed and signed. This gives the supervisee the opportunity to review the supervisor's qualifications, understand the supervision approach, and ask questions before committing to the supervisory relationship. In states like Oregon that regulate disclosure timing, the statement must be provided prior to the actual performance or provision of service. Best practice is to send the disclosure document in advance and then review it together at the initial meeting.

Does the supervisor disclosure statement need to be updated?

Yes. The supervisor disclosure statement should be updated whenever there is a material change in the information it contains — for example, a change in the supervisor's licensure status, theoretical orientation, supervision approach, fees, contact information, or the applicable grievance procedure. Additionally, if your state's regulations governing supervision change, the disclosure should be revised to reflect current requirements. Best practice is to review the document annually and update it as needed. If a revision is made during an active supervisory relationship, provide the updated version to the supervisee and retain both the original and updated versions in the supervisory record.

What is the difference between a supervisor disclosure statement and a supervision contract?

The supervisor disclosure statement is a one-directional informational document from the supervisor to the supervisee. It tells the supervisee who the supervisor is, how they approach supervision, and what the supervisee can expect. The supervision contract is a bilateral agreement between both parties, establishing mutual obligations, expectations, and terms. Think of the disclosure statement as 'here is who I am and how I work' and the contract as 'here is what we both agree to do.' Both are essential: the disclosure informs, and the contract binds. In practice, some supervisors combine elements of both into a single document, but maintaining them as separate documents is cleaner from a regulatory and organizational perspective.

Supervisor Disclosure Statement Template

Supervision|15 min read|Updated 2026-03-20|Clinically reviewed

What Is a Supervisor Disclosure Statement?

A supervisor disclosure statement is a written document provided by a clinical supervisor to a prospective or new supervisee that transparently communicates the supervisor's qualifications, theoretical orientation, approach to supervision, expectations, confidentiality policies, evaluation methods, and grievance procedures. It serves the same ethical function as a therapist's informed consent with a client — ensuring that the supervisee enters the supervisory relationship with full knowledge of what to expect.

The concept of informed consent extends beyond the therapy room. The APA Ethics Code (Standard 7.01) requires psychologists involved in education and training to provide accurate descriptions of program expectations, evaluation criteria, and the nature of the experience. The APA Guidelines for Clinical Supervision in Health Service Psychology further specify that supervisors should be transparent about their supervisory approach, their theoretical orientation, and the methods they use to evaluate supervisee competence. The ACES Best Practices in Clinical Supervision recommend that supervisors provide a written statement of supervision policies and procedures at the outset of the supervisory relationship.

From a regulatory perspective, several states have codified these professional recommendations into law. Oregon requires all licensed counselors and supervisors to provide a Professional Disclosure Statement (PDS) before services begin. North Carolina's Board of Licensed Clinical Mental Health Counselors requires professional disclosure as part of the counseling and supervision process. Washington State's WAC 246-810-031 mandates specific disclosures including the type and duration of services, limits of confidentiality, and supervisory or consultation arrangements. Michigan and Arizona require supervisees to present clients with written documentation of their supervisee status and the supervisor's identity — which presupposes that the supervisor has provided this information to the supervisee in writing.

Even in states without explicit regulatory mandates, a supervisor disclosure statement demonstrates professionalism, transparency, and compliance with national ethical standards. It sets the tone for the supervisory relationship and reduces the likelihood of misunderstandings about expectations, methods, or procedures.

When You Need It

Before beginning a new supervisory relationship with any pre-licensed clinician, intern, or trainee
When a prospective supervisee is evaluating whether to enter a supervisory relationship with you
When your state licensing board requires a Professional Disclosure Statement as part of the supervision process
When a training program requests documentation of your supervision qualifications and approach
When updating your supervision practices and need to communicate changes to current supervisees
When a supervisee transitions from one supervisor to another within the same organization

Key Components

1. Supervisor Qualifications and Credentials

Provide your full name, highest relevant degree, licensure type, license number, state of licensure, and any additional certifications relevant to supervision (such as board certification, approved clinical supervisor designation, or specialty certifications). Include the number of years you have been licensed and the number of years you have been providing clinical supervision. If you have completed formal training in supervision — such as a graduate course in supervision theory and practice, a supervision certificate program, or supervision-focused continuing education — state this as well.

2. Clinical Experience and Areas of Specialization

Describe your clinical background and areas of specialization. Supervisees need to know whether your expertise aligns with the population and presenting concerns they will be treating. Include the clinical populations you work with (adults, adolescents, children, couples, families), the settings in which you have worked (private practice, community mental health, hospitals, university counseling centers), and your areas of clinical specialization (anxiety, depression, trauma, substance use, eating disorders, etc.).

3. Theoretical Orientation

State your primary theoretical orientation and how it informs your approach to both clinical practice and supervision. If you are integrative, describe the models you draw upon. The supervisee should understand the theoretical lens through which you will evaluate their clinical work. For example, a supervisor grounded in CBT will emphasize different aspects of case conceptualization than one grounded in psychodynamic theory. Transparency about your orientation helps the supervisee assess fit and prepare for the kind of feedback they will receive.

4. Supervision Philosophy and Approach

Describe your approach to supervision. Do you use a developmental model (adjusting your approach based on the supervisee's experience level)? A competency-based model (organized around measurable competency domains)? A discrimination model (shifting between teacher, counselor, and consultant roles depending on the supervisee's needs)? How do you balance support and challenge? How do you handle differences in theoretical orientation between you and the supervisee? What supervision modalities do you use — case discussion, live observation, recording review, role-play, didactic instruction?

5. Evaluation Methods and Criteria

Explain how and when you will evaluate the supervisee's competence. Describe the evaluation instruments you use, the frequency of formal evaluations (e.g., mid-year and end-of-year), the competency domains assessed, and the rating scale employed. Explain that evaluations will be discussed in a dedicated session and that the supervisee will have the opportunity to review, discuss, and respond to evaluations.

6. Confidentiality in Supervision

Describe the confidentiality policies that apply within the supervisory relationship. The supervisee should understand that case material discussed in supervision is treated as confidential, with specific exceptions: mandatory reporting obligations, licensing board requests, court orders, and situations where the supervisee's conduct poses a risk to client welfare. If group supervision is part of the arrangement, explain the confidentiality expectations for all group members.

7. Expectations for the Supervisee

Outline what you expect from supervisees: preparation for sessions, honest case presentation, timely documentation, adherence to ethical standards, implementation of feedback, accurate hour tracking, and disclosure of supervisee status to clients. This section sets clear expectations from the outset and provides a reference point if expectations are not met.

8. Grievance Procedures

Provide a clear process for the supervisee to raise concerns about the supervisory relationship. Include informal resolution steps (direct discussion), formal steps if needed (mediation, escalation to a training program director), and external options (filing a complaint with the state licensing board). Include the licensing board's contact information. The supervisee should know from day one that they have recourse if they believe supervision is inadequate, unfair, or harmful.

9. Fees (If Applicable)

If you charge a fee for supervision, state the amount, payment schedule, and accepted payment methods. If supervision is part of an employment arrangement and no separate fee is charged, state that as well. Transparency about compensation prevents misunderstandings.

10. Contact Information and Availability

Provide your office phone, email, and emergency contact number. State your typical response time for non-urgent communications and your availability for emergency consultation outside business hours.

Supervisor Disclosure Statement Example

Supervisor Professional Disclosure Statement

SUPERVISOR PROFESSIONAL DISCLOSURE STATEMENT

Supervisor: Maria Gonzalez, PsyD License: Licensed Clinical Psychologist, PSY 31204 (State of California) Practice: Westside Psychological Services Address: 4500 Ocean Avenue, Suite 220, Los Angeles, CA 90066 Phone: (310) 555-0187 | Email: mgonzalez@westsidepsych.com Emergency Contact: (310) 555-0199 (cell)

QUALIFICATIONS

I am a licensed clinical psychologist in the State of California. I received my Doctor of Psychology (PsyD) degree from the California School of Professional Psychology at Alliant International University in 2012. I completed my pre-doctoral internship at the VA Greater Los Angeles Healthcare System and my postdoctoral fellowship at Cedars-Sinai Medical Center. I have been licensed since 2014 and have been providing clinical supervision since 2017. I have completed graduate-level coursework in supervision theory and practice and have attended over 40 hours of continuing education specifically focused on clinical supervision.

CLINICAL EXPERIENCE AND SPECIALIZATION

I have worked in community mental health, hospital, and private practice settings over the past fourteen years. My clinical specialization areas include anxiety disorders, depressive disorders, trauma and PTSD, and adolescent psychology. I have extensive experience with cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and psychodynamic psychotherapy. My current practice is an outpatient private practice serving adolescents and adults.

THEORETICAL ORIENTATION

My primary theoretical orientation is integrative, drawing primarily from cognitive behavioral and acceptance-based frameworks. In clinical work, I emphasize evidence-based interventions tailored to the individual client's needs, with attention to the therapeutic relationship as a vehicle for change. I also draw on psychodynamic concepts — particularly attachment theory and object relations — when understanding relational patterns and the therapeutic alliance.

SUPERVISION PHILOSOPHY AND APPROACH

I approach supervision from a developmental perspective, meaning I adjust my supervisory style based on the supervisee's experience level and needs. With early-career supervisees, I tend to be more directive and instructional, providing explicit guidance on case conceptualization, intervention selection, and documentation. As supervisees develop confidence and competence, I shift toward a more consultative and collaborative approach, encouraging independent clinical decision-making while remaining available for guidance.

I use a competency-based framework, organizing supervision around the professional competency domains identified by the APA: assessment and diagnosis, intervention, ethical and legal practice, individual and cultural diversity, professional values and attitudes, clinical documentation, and supervision utilization. I believe effective supervision balances support with challenge — affirming strengths while honestly addressing areas for growth.

My supervision methods include:

Case discussion: The primary modality in most sessions. The supervisee presents cases and we discuss clinical issues, intervention strategies, and conceptualization.
Documentation review: I regularly review the supervisee's progress notes, treatment plans, and assessments, providing written and verbal feedback.
Recording review: When appropriate and with client consent, we may review audio or video recordings of sessions to provide direct feedback on clinical skills.
Role-play and skill practice: For specific techniques or challenging clinical situations, we may use role-play in supervision.
Didactic instruction: When the supervisee needs foundational knowledge in a specific area, I provide targeted teaching within supervision or recommend readings, workshops, and training.

I welcome supervisees whose theoretical orientation differs from mine. While I will share my perspective, I do not require supervisees to adopt my orientation. I do require that supervisees use evidence-based practices and can articulate a coherent clinical rationale for their interventions.

EVALUATION

I conduct formal written evaluations of supervisee competence at the midpoint and end of each training year (or at equivalent intervals for shorter supervisory periods). Evaluations use a structured competency evaluation form with behavioral anchors and a 5-point rating scale. Each evaluation includes domain-specific ratings, narrative feedback identifying strengths and growth areas, and recommendations for continued development. Evaluations are reviewed in a dedicated supervision session, and supervisees have the opportunity to ask questions and provide a written response.

Informal feedback is provided at every supervision session. If I identify a concern about a supervisee's competence, I will address it directly and promptly. If a formal remediation plan becomes necessary, it will be developed collaboratively, documented in writing, and reviewed at regular intervals.

CONFIDENTIALITY

Information shared in supervision — including case material, the supervisee's self-reflections, and evaluation data — is treated as confidential, with the following exceptions:

Mandatory reporting: If supervision reveals information that triggers a mandatory reporting obligation (child abuse, elder abuse, imminent danger to self or others), the supervisor will ensure the report is made.
Licensing board inquiries: The supervisor may be required to provide information to the California Board of Psychology in response to an investigation, audit, or application review.
Legal proceedings: Supervision records may be subject to subpoena or court order.
Client safety: If the supervisee's conduct poses a risk to client welfare, the supervisor may take protective action, which may include reporting to the licensing board or the supervisee's employer.
Group supervision: If the supervisee participates in group supervision, all group members are expected to maintain confidentiality regarding case material and peer feedback.

EXPECTATIONS FOR SUPERVISEES

I expect supervisees to:

Attend all scheduled supervision sessions prepared to discuss clinical cases, raise questions, and review documentation
Complete clinical documentation within 48 hours of each session and submit it for review
Inform all clients of their supervisee status, including the supervisor's name and contact information, as part of the informed consent process
Implement supervisor directives in a timely manner and discuss any disagreements openly in supervision
Track clinical and supervision hours accurately and submit logs for verification monthly
Adhere to the APA Ethics Code, California law, and all practice policies
Seek emergency consultation when client safety concerns arise, without delay

GRIEVANCE PROCEDURES

If you have a concern about any aspect of the supervisory relationship, I encourage you to raise it directly with me. I am committed to addressing concerns openly and constructively. If direct discussion does not resolve the concern:

You may request mediation through a mutually agreed-upon third party
You may contact the practice director at Westside Psychological Services
You may file a complaint with the California Board of Psychology:

California Board of Psychology 1625 North Market Blvd., Suite S-200 Sacramento, CA 95834 Phone: (866) 503-3221 Website: www.psychology.ca.gov

You have the right to seek external consultation or file a complaint at any time without retaliation.

FEES

Supervision is provided as part of the supervisee's employment arrangement at Westside Psychological Services. There is no separate supervision fee.

AVAILABILITY

I am available during business hours (Monday through Friday, 9:00 AM to 5:00 PM) by phone and secure email. For non-urgent matters, I respond within one business day. For clinical emergencies, contact me by cell phone at (310) 555-0199. If I am unavailable, contact the backup supervisor, Dr. Priya Sharma, PsyD (PSY 28903) at (310) 555-0234.

ACKNOWLEDGMENT

By signing below, I acknowledge that I have received, read, and understand this Supervisor Professional Disclosure Statement. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction.

Supervisee Signature: ______________________________ Date: ______________ Supervisee Printed Name: ______________________________

Supervisor Signature: ______________________________ Date: ______________

This is a sample for educational purposes only — not real patient data.

How to Write a Supervisor Disclosure Statement

Step 1: Research your state's requirements. Before writing, check whether your state licensing board mandates a Professional Disclosure Statement for supervisors. If a required format or specific content elements are prescribed, start with those. States like Oregon, North Carolina, and Washington have explicit requirements that must be met. Even if your state does not mandate a disclosure statement, the APA and ACES recommend one.

Step 2: Be honest about your qualifications. Include your actual credentials, training, and experience — do not overstate your expertise or omit relevant limitations. If your supervision training consists of a single workshop rather than graduate coursework, state what you have completed. Transparency builds trust and protects you if your qualifications are later scrutinized.

Step 3: Describe your supervision approach in plain language. Avoid excessive jargon. The supervisee should genuinely understand how you approach supervision, not just recognize the names of theoretical models. Explain what your approach means in practice — what will sessions look like, how will feedback be delivered, what will you focus on?

Step 4: Be specific about evaluation. Vague statements about "ongoing evaluation" do not give the supervisee meaningful information. Specify when formal evaluations will occur, what instruments will be used, which competency domains will be assessed, and how the evaluation process works (including the supervisee's right to review and respond).

Step 5: Include grievance procedures with contact information. This is the section supervisors most often omit, and it is one of the most important. A supervisee who does not know how to raise a concern may suffer in silence or go directly to the licensing board without attempting resolution. Provide a clear, stepwise process with specific contact information for external resources.

Step 6: Review with the supervisee and obtain signatures. Do not email the disclosure and assume it was read. Review it in person at the first meeting, invite questions, and discuss any concerns. Obtain the supervisee's signature acknowledging receipt and understanding. Retain the signed original in your supervisory record.

Common Mistakes

Omitting the disclosure statement entirely. Many supervisors provide a supervision contract but not a disclosure statement, assuming that the contract covers everything. The contract is a bilateral agreement about obligations; the disclosure is a unilateral statement about who you are, how you work, and what the supervisee can expect. Both are needed. In states that require a Professional Disclosure Statement, omitting it is a regulatory violation.
Providing a disclosure that reads as a marketing document. A disclosure statement is not a biography or a practice brochure. It should be informative and transparent, not promotional. Focus on the information the supervisee needs to make an informed decision about the supervisory relationship, not on making yourself sound impressive.
Failing to include grievance procedures. Without a written grievance process, the supervisee has no structured path to raise concerns. This omission can lead to unresolved conflicts, power imbalances, and licensing board complaints that might have been resolved internally. Include the process, including external options, and provide specific contact information for the licensing board.
Not updating the disclosure when circumstances change. If your licensure status, theoretical orientation, supervision approach, fees, or contact information changes, the disclosure must be updated. An outdated disclosure is misleading and, in regulated states, may constitute a violation.
Using language that is too technical for the audience. While supervisees are clinical professionals, they may not be familiar with supervision-specific terminology like "discrimination model" or "isomorphism." Describe your approach in terms the supervisee can understand. If you use theoretical terms, define them.
Treating the disclosure as a one-time document. Like informed consent in therapy, the supervisor disclosure statement should be a living reference point. Revisit it when questions arise about evaluation criteria, confidentiality boundaries, or grievance procedures. It sets the framework for the entire supervisory relationship and should be consulted, not filed and forgotten.