Black Therapist & Company, LLC

Sample Pre-Licensed Supervision Agreement

Black Therapist & Company, LLC owned and operated by Rosemarie Hemmings, Ph.D., LCSW in agreement with XXXXXX

Agrees to the following:

a)     Provide anti-racist, cultural-specific trauma-informed decolonized individual and/or group clinical supervision to pre-licensed social workers.
b)     Preference will be given to pre- licensed clinicians who identify as BIPOC.
c)      Acceptance of a pre-licensed social worker into clinical supervision is the sole decision of Dr. Hemmings in consultation with the pre-licensed social worker.
d)     Each pre-licensed social worker will enter into a supervisor agreement independently with Dr. Hemmings for Oregon Board of Social Workers requirement.
e)     Per the Board requirements, clinical supervision will be a minimum: individual twice per month for one hour and/or group (Max 100 hrs. of individual and 50hrs of group). Group supervision is not required by the Board.
f)       Dr. Hemmings will have access to pre-licensed social workers notes and allowed to make recommendations related to case assignment and treatment plan as required by Oregon Board of Social Workers.
g)     With the exception of ethical and other Board of Social Workers violations, the supervisory space will be considered confidential: whereby, Dr.
Hemmings will use her discretion as to what to share with XXXX
h)     Dr Hemmings will charge an hourly rate for all meetings requested by the contracting agency.
i)       Dr. Hemmings and/or the pre-licensed clinician can terminate the supervisory agreement with 30 days’ written notice (Board and XXXX will be notified).
j)       Payment will be due upon invoice and payable within 10 days of receipt.
k)     This agreement between XXXX and Black Therapist & Company, LLC can be terminated with 30 days’ written notice by either party.