Supervision Proof Document

SUPERVISION PROOF DOCUMENT

Document Reference Number:

Parties and Contact Information

WHEREAS (Recitals)

WHEREAS, Supervisor is engaged to provide supervision of certain services performed by Service Provider ;

WHEREAS, the parties wish to document and certify that supervision sessions described herein were conducted in accordance with applicable professional standards and the terms set forth in this document as proof of supervision for regulatory, billing, or contractual purposes.

Scope of Work / Supervision Activities

Supervisor shall provide supervision consisting of review, direct observation, feedback, and documentation of the Service Provider's performance as described below. The supervision scope includes frequency, format, and specific objectives.

Supervision Method: In-person Remote/Tele-supervision Hybrid

Frequency and Duration:   Session Length:

Proof of Supervision and Certification

Supervisor certifies that the supervision activities listed below were completed and that supporting documentation exists as described. The Supervisor affirms that the documentation accurately reflects the dates, participants, and content of supervised sessions.

From    To

Supporting documentation attached or available upon request includes session notes, attendance logs, recordings where permitted, and written evaluations. List supporting documents below.

Payment Terms

Compensation for supervision services shall be as follows. Parties agree the Supervisor's fees cover documentation and certification time as described in this document.

Late Payment Fee:    Invoices Due Within: days of receipt.

Term and Termination

This Supervision Proof Document becomes effective as of and shall continue until unless earlier terminated in accordance with this section.

Either party may terminate for any reason by providing written notice to the other party at least days prior to the effective termination date. Termination for material breach may be immediate if the breaching party fails to cure within a reasonable time after notice.

Confidentiality

Each party acknowledges that in the course of supervision, confidential or proprietary information may be disclosed. The receiving party shall: (a) maintain such information in strict confidence; (b) not disclose such information except to employees or contractors who need to know and who are bound to protect confidentiality; and (c) use the information only to carry out obligations under this document. Confidential information does not include information that is publicly known through no breach by the receiving party, independently developed by the receiving party, or required to be disclosed by law provided the disclosing party is given prompt notice to seek protective measures.

Governing Law

This document and any dispute arising out of or related to it shall be governed by the laws of , without regard to conflict of law principles.

Entire Agreement

This document constitutes the entire agreement between the parties concerning proof and certification of supervision and supersedes all prior and contemporaneous agreements, understandings, and representations, whether written or oral, relating to its subject matter. Any amendment must be in writing and signed by both parties.

Acknowledgment and Certification

By signing below, each party certifies that the information set forth in this Supervision Proof Document is true and accurate to the best of their knowledge, that supervision was conducted as described, and that the signatory is authorized to execute this document on behalf of the party identified.

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