Clinical Supervision Guides›Free Supervision Toolkit›Disclosure Statement
Last updated: November 4, 2026
A supervision disclosure statement is a written description, given to a new supervisee, of how supervision will work: your qualifications, what supervision includes, each person's responsibilities, how evaluation works, the limits of confidentiality, recordings, emergencies, boundaries, fees and how supervision ends. The template below has twelve sections with example wording, ready to fill in. Delete the sections that do not apply and replace the bracketed text.
The statement is part of the Sentio MFT program's free clinical supervision toolkit.
This is an optional aid from the Sentio MFT program's clinical supervision toolkit. This is not a BBS form.
| Section | What to write (example wording in italics) |
|---|---|
| 1. About me as a supervisor | License type and number, years licensed, supervision training, theoretical orientation and the areas of practice I am competent to supervise. |
| 2. What supervision includes | Frequency and length; individual, triadic or group format; in person or by videoconference; what to bring (cases, notes, recordings); how we set and review goals in the supervisory plan. |
| 3. My responsibilities | I am responsible for the quality of the services you provide under my supervision. I will review your notes and recordings, give you regular feedback, sign your weekly log every week, and be reachable in emergencies as our written emergency procedures describe. |
| 4. Your responsibilities | Prepare for each session. Tell clients what California law requires you to tell them about your status and supervision. Bring risk concerns to me promptly. Obtain written client consent before recording. Keep your weekly log current. Tell me about changes in your registration, your employment or your other supervisors. |
| 5. Evaluation | I will give you feedback in every session. At least once a year, and when supervision ends, I will write an assessment of your strengths and limitations based on the goals in our supervisory plan and on [notes, recordings, observation], and give you a copy. If a concern about your work arises, I will tell you promptly, describe it in writing with specific examples, and agree a plan with you. |
| 6. Confidentiality and its limits | What we discuss in supervision stays between us, except when a client or someone else may be at risk, when the law requires a report, when the Board of Behavioral Sciences requests records, or when [your employer or training program] receives evaluations as agreed. |
| 7. Recordings | How recordings are made, stored, shared with me and deleted, and the written client consent required before any recording. |
| 8. Emergencies | A summary of the written emergency procedures, which you receive before supervision begins. |
| 9. Boundaries | I will not provide therapy to you, and we will avoid any other relationship that could undermine supervision. If our paths cross professionally, we will discuss how to keep supervision effective. |
| 10. Fees, if any | Amount, payment schedule and cancellation terms. |
| 11. Disagreements and concerns | Raise a disagreement with me first. If we cannot resolve it, [employer or program contact] can help. The Board of Behavioral Sciences accepts complaints about licensees. |
| 12. Ending supervision | Either of us may end supervision. I will give you at least one week's written notice before I stop signing for further hours, as California regulations require, and I will complete a final assessment and your Experience Verification. |
| Signatures | Supervisor, supervisee, date. This statement supplements the BBS Supervision Agreement. |
What Must a Supervisee Be Told in California?
Several California rules set what a supervisee should know before supervision starts, and the statement gathers them in one place. The supervisor must give written procedures for reaching the supervisor or an on-call alternate in an emergency before supervision begins, must tell the supervisee at once of any discipline or lapse that affects the supervisor's license, and must assess the supervisee's strengths and limitations at least once a year and when supervision ends, with a copy to the supervisee (16 CCR 1833.1(a)). Before refusing to sign for further hours, the supervisor must give at least one week's written notice (16 CCR 1833.1(b)). The Board's Supervision Agreement, signed within 60 days of the start of supervision, records the legal affirmations and the supervisory plan; the statement covers how the supervision itself will work.
Section 4 of the statement reminds the supervisee of what they must tell clients. Through December 31, 2026, an associate marriage and family therapist must tell each client, before providing services, that they are an unlicensed registered associate, give their registration number and the name of their employer, and say what type of license their supervisor holds (BPC 4980.44(a)). From January 1, 2027, AB 1598 requires every applicant, registrant and trainee to tell each client that they are unlicensed and supervised by a licensed professional, and to give the name of their employer or of the organization they volunteer for. Our guide to ethics and liability in clinical supervision covers informed consent in both directions, and the Clinical Supervision Guides cover the consent, boundary and payment questions the statement answers.
Is a Disclosure Statement the Same as a Supervision Contract?
No. The disclosure statement tells a supervisee how you supervise: your qualifications, how evaluation and confidentiality work and what happens if concerns arise. A supervision contract is an agreement between the parties, usually including the employer, about the business of supervision: who pays, how much, the schedule, cancellations, records, insurance and how the arrangement ends. The American Psychological Association's 2025 guidelines describe the supervision contract as an informed consent document, and many supervisors combine the two. Private practices and supervisors who are paid by the supervisee usually need both. Our clinical supervision contract template covers the agreement, with a California addendum.
Keep reading
Clinical Supervision Contract Template, the business agreement for private practice and agency supervision, with a California addendum
Supervision Emergency Procedures Template, the written procedures section 8 summarizes
Ethics and Liability in Clinical Supervision, dual relationships, gatekeeping and informed consent
Your First Supervisee, everything due before the first session
Frequently Asked Questions
What is a supervision disclosure statement?
A written statement a supervisor gives a new supervisee describing how supervision will work: qualifications, format, responsibilities, evaluation, confidentiality and its limits, recordings, emergencies, boundaries, fees and how supervision ends.
Is a supervision disclosure statement required in California?
No rule requires one by that name. California does require the Supervision Agreement within 60 days, written emergency procedures before supervision begins, the yearly and final assessment and one week's written notice before a supervisor stops signing for hours, and the statement tells the supervisee about each of them at the start.
What must an associate tell clients about supervision?
Through December 31, 2026, an associate marriage and family therapist tells each client they are an unlicensed registered associate and gives their registration number, their employer's name and their supervisor's license type. From January 1, 2027, applicants, registrants and trainees tell each client they are unlicensed and supervised by a licensed professional and give the name of their employer or volunteer organization.
Should the disclosure statement cover fees?
Yes, if the supervisee pays you. State the amount, the payment schedule and the cancellation terms, or use a separate supervision contract for the business terms.
References
American Psychological Association. (2025). Guidelines for clinical supervision in health service psychology. https://www.apa.org/about/policy/guidelines-supervision.pdf
Assembly Bill 1598, Chapter 528, Statutes of 2026 (Cal. 2026). https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202520260AB1598
California Business and Professions Code § 4980.44. https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC§ionNum=4980.44
Board of Behavioral Sciences. (2026). Supervision agreement (DCA BBS 37M-300, rev. 05/2026). https://www.bbs.ca.gov/pdf/forms/supervision_agreement.pdf
Cal. Code Regs. tit. 16, § 1833.1. https://govt.westlaw.com/calregs/Document/I018363124C8211EC89E5000D3A7C4BC3
