Free Supervisor Affidavit-F-62570 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62570 (Rev. 07/08)

STATE OF WISCONSIN

SUPERVISOR AFFIDAVIT
Completion of this form is voluntary; however, the information provided to the Department will be used to confirm that clinic personnel employed by a psychotherapy provider meet the minimum requirements as specified in HFS 61.96 and 61.97, Wisconsin Administrative Code. Failure to provide the information requested on this form may result in denial of the application.
Name ­ Applicant Date Submitted

The applicant has applied for approval as an outpatient psychotherapy provider and to qualify for third party insurance and other mandated benefits reimbursement. In addition to appropriate master's degree educational credentials, the applicant must accumulate a total of 3,000 hours of post-master's clinical practice experience (defined as providing psychotherapy to clients with a primary diagnosis of mental illness under DSM-IV) under qualified supervision. For every 40 hours of clinical practice, the applicant must have received a minimum of one hour of supervision from one of the following "qualified" professionals: a master's degreed social worker (MSW) or other master's prepared professional who has individual provider status approval; a master's degreed psychiatric nurse; a psychiatrist or licensed psychologist that would meet Wisconsin licensure / certification requirements. This is an affidavit that you have provided supervision during the period indicated and that you meet the appropriate supervisory credentials.

SUPERVISOR'S STATEMENT I. I provided a minimum of one hour of supervision, for each 40 hours of clinical practice, while the applicant served as a mental health psychotherapy clinician.
Agency and Address Applicant Dates Hours of Qualifying Practice

TOTAL HOURS
II. Describe applicant's functions below.

III. I swear that the information provided is true and correct.
SIGNATURE ­ Supervisor Date Signed

IV. Qualification of Supervisor (Check all that apply.) MD Psychiatrist (License Number:

_________ )
__________ )

Licensed "Clinical" Psychologist (License Number: Qualified MSW Social Worker Qualified Master's Degree Psychiatric Nurse 3,000 Hours Approved Provider