Recco S. Richardson Consulting Inc.

Group/Individual Supervision Note

Participant’s Name:___________________________________________________________________

Date:______________      Session Time:______________ Session Time Out:_______________

Supervision Topic:_____________________________________________________________________

 

♦ Intervention:

(  ) Education (  ) Supportive (  ) Clarification

(  ) Confrontation (  ) Problem Solving (  ) Venting

(  ) Exploration (  ) _____________ (  ) __________

 

♦ Emotional Response:

(  ) Calm (  ) Anxious (  ) Sad

(  ) Angry (  ) Hostile (  ) Happy

(  ) Guilty (  ) Mourning (  ) Detached

 

♦ Behavioral Response:

(  ) Good eye contact (  ) Good attention span (  ) Happy

(  ) Poor attention span (  ) Reaching out (  ) Poor eye contact

(  ) Hyperactive (  ) Withdrawn (  ) Inappropriate

 

♦ Cognitive Response:

(  ) Insightful (  ) Denial (  ) Rationalizing

(  ) Withholding (  ) Projecting blame (  ) Questioning

(  ) Not identifying (  ) Not focused (  ) Displaying anger

(  ) Unrealistic                (  ) Realistic solutions (  ) Relates to material

 

 

Supervisor’s  Input: _____________________________________________________________________________________

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Supervisor’s  Signature                                                                 Date