Pauline O’Brien’s Clinical Supervision and Consultation Agreement

Draft revised: October 23, 2026

This agreement describes our professional relationship, responsibilities, confidentiality, evaluation, fees, and arrangements for working together. We will complete the applicable fields before beginning, review the agreement when circumstances change, and each retain a signed copy.

1. Professional disclosure

I am a Registered Psychotherapist with the College of Registered Psychotherapists of Ontario (CRPO #001225).

I hold an Honours Bachelor of Arts (BA) in Psychology (2002) and a Master of Education (M.Ed.) in Counselling (2004) from the University of Ottawa, and an Ed.D. in Counselling Psychology from the Ontario Institute for Studies in Education, University of Toronto (2016).

I am also a Canadian Certified Counsellor-Supervisor (#249) with the Canadian Counselling and Psychotherapy Association.

I have more than 20 years of counselling and psychotherapy experience and have supervised clinicians and students since 2007. My work includes psychotherapy, clinical supervision, and teaching in Yorkville University’s Master of Arts in Counselling Psychology program.

My practice experience includes work with 2SLGBTQIA+ communities, clinical complexity, neurodivergence, mental health, addictions, trauma, Indigenous mental health, perinatal mood concerns, and crisis intervention. We will establish whether my competence and experience are appropriate for the services you provide.

I undertake supervision only where I meet the applicable qualifications. CRPO does not individually approve or certify clinical supervisors. My CRPO registration and CCPA supervisor credential do not constitute BCACC’s Approved Clinical Supervisor designation.

2. Service and purpose

Name: __________________________________________

Professional designation, registration number, and jurisdiction:
__________________________________________________

Practice, employer, or education program:
__________________________________________________

Service agreed upon:

☐ Clinical supervision
☐ Professional consultation
☐ Supervision of supervision — separate addendum required

Clinical supervision involves professional learning, support, evaluation, and oversight within an agreed scope. Client welfare, safe care, and public safety take priority alongside supervisee development.

Consultation provides advice and reflection on specified practice questions. The practitioner remains responsible for deciding how to use recommendations. Consultation does not automatically establish a supervisory relationship or satisfy required supervision.

These services do not establish a psychotherapy relationship between us. Personal experiences may be explored when relevant to practice; personal treatment needs will be referred to a separate provider.

3. Approach, learning, and cultural safety

My approach is collaborative, relational, reflective, trauma-informed, and attentive to power and professional context.

We may explore clinical formulation, treatment planning, therapeutic relationships, ethics, documentation, professional boundaries, client safety, vicarious trauma, burnout, accessibility, and sustainable practice.

I aim to practise with cultural humility and to examine how my assumptions, identities, privileges, and professional authority influence our work. We will attend to racism, colonialism, systemic inequities, Indigenous cultural safety, and the cultural and community contexts of clients and supervisees.

We will discuss learning preferences, accessibility needs, and ways to make feedback useful. Consultation with culturally relevant resources or other professionals may be recommended where appropriate.

Learning goals:
__________________________________________________
__________________________________________________

Client populations, settings, and therapeutic approaches included:
__________________________________________________

Services or activities outside the agreed scope:
__________________________________________________

Supervision may involve challenging feedback and reflection on mistakes or uncertainty. You are encouraged to discuss concerns about our relationship or approach. Particular learning outcomes, registration decisions, or placement results cannot be guaranteed.

4. Responsibilities and client accountability

My responsibilities

I will:

• Work within my competence and the agreed supervisory role.
• Provide respectful feedback and identify concerns about competence or safety.
• Adapt supervision to your experience, caseload, and clinical needs.
• Maintain appropriate records, boundaries, and professional liability coverage.
• Seek consultation or supervision of supervision when needed.
• Fulfil applicable legal, ethical, and professional obligations.

Your responsibilities

You agree to:

• Accurately describe your qualifications, registration status, practice, and supervision requirements.
• Practise within your competence and legal authority.
• Attend prepared and disclose material information needed for effective supervision.
• Raise significant safety concerns, adverse events, complaints, and difficulties practising safely promptly.
• Discuss feedback, uncertainties, disagreements, and barriers to implementing recommendations.
• Maintain required client consent, records, insurance, and supervision logs.
• Identify other supervisors and clarify overlapping responsibilities.

Neither party’s accountability is removed by this agreement.

Whose clients are involved?
☐ Your practice ☐ Agency/placement ☐ My practice
☐ Other: __________________________________________

Responsibility for ongoing care, clinical decisions, emergency response, and referrals:
__________________________________________________

Custodian or organization responsible for client records:
__________________________________________________

Other supervisors, organizational contacts, and respective responsibilities:
__________________________________________________

These arrangements must be clarified before supervision begins.

5. Meetings and methods

Start date: ______________________________________

Review date: _____________________________________

Format: ☐ Individual ☐ Dyadic ☐ Group

Number of supervisees: ____________________________

Frequency and duration: ___________________________

Location/platform: _________________________________

Methods may include case discussion, self-report, formulation, clinical-record review, skills practice, live observation, or review of recordings with appropriate consent.

Agreed review methods:
__________________________________________________

Frequency and methods will be reviewed when caseload, competence, complexity, or safety needs change.

For dyadic or group work, records will distinguish attendance, active presentation, and observed clinical work. Hour categories will be applied according to the relevant organization’s requirements; attendance alone does not establish entitlement to every category of credit.

6. Feedback, evaluation, and concerns

Clinical supervision includes ongoing evaluation. We will establish learning goals and evaluation criteria alongside applicable professional, educational, and client-safety requirements.

Evaluation may include my observations, your self-assessment, your feedback on supervision, and client feedback where appropriate and available.

Criteria, methods, and review dates:
__________________________________________________

Formal reports, recipients, and disclosure arrangements:
__________________________________________________

If concerns arise, I will ordinarily explain and document them, invite your response, and establish a learning or remediation plan where appropriate. Additional training, closer supervision, changes to clinical activities, or referral may be necessary.

Routine mistakes and learning needs are not automatically grounds for reporting. Serious unsafe practice, misconduct, or incompetence may require protective action or a report under applicable obligations.

Payment does not guarantee a favourable evaluation, reference, or attestation.

7. Confidentiality and reporting

Information shared in supervision or consultation is confidential within the agreed arrangements and applicable law.

We will identify any planned disclosures to educational institutions, employers, placement sites, other supervisors, or professional organizations, including their purpose and scope. Appropriate consent will be obtained unless disclosure is otherwise legally permitted or required.

Limits may include significant risks of serious harm, applicable mandatory reports, legally compelled disclosure, regulatory processes, and agreed evaluation or placement reporting.

Where reasonably possible and legally permitted, I will discuss a necessary disclosure beforehand. Urgent circumstances or legal requirements may prevent advance discussion. Disclosure will be limited to what is reasonably necessary.

8. Client information, records, and privacy

You must inform clients of applicable supervision arrangements and obtain appropriate consent before sharing identifiable information, documents, or recordings. Where applicable, clients will receive my identity, contact details, role, and information about contacting me concerning supervised services.

Use de-identified information wherever reasonably possible. Identifiable material must be exchanged only through an agreed, appropriately secure method.

Clinical supervision records maintained in my practice are stored securely in Jane App. Further information is available in my Privacy Policy.

We will identify the privacy laws and organizational requirements applicable to both parties and the client setting. These may include Ontario’s PHIPA, British Columbia’s PIPA or public-sector privacy legislation, and federal legislation where applicable. This agreement does not replace either party’s legal obligations.

Information shared, secure-transfer method, permitted access, storage, retention, and disposal arrangements:
__________________________________________________
__________________________________________________

Recordings, transcription, and AI tools require prior discussion, appropriate consent, and suitable safeguards. This agreement does not authorize uploading identifiable client material to an AI service.

Group participants must protect information about clients and colleagues. Other participants’ confidentiality cannot be guaranteed.

I maintain records of attendance, duration, format, issues discussed, feedback, directions, and relevant concerns. You must maintain your own accurate supervision records.

Requests for supervision documentation will be addressed within a negotiated, reasonable timeframe, subject to privacy obligations and lawful exceptions.

9. Recognition and verification of hours

We will identify the professional or educational purpose of supervision before relying on it for recognition.

Organization and specific requirements:
__________________________________________________

Required forms and deadlines:
__________________________________________________

I will verify only activities and hours I can substantiate. Consultation will not be characterized as qualifying supervision unless the arrangement and work meet the applicable requirements.

Regulators, associations, educational institutions, and certifying bodies determine acceptance. Recognition cannot be guaranteed.

BCACC ACS-related supervision of supervision requires the separate addendum below and confirmation that the supervisor and arrangement meet the relevant criteria.

10. Remote services and availability

Services may occur in Hamilton, Ontario, or through Jane Video, Zoom, or telephone, as agreed.

Both parties will use private settings and discuss technology risks, safeguards, and a backup plan. Please disclose participation from another jurisdiction so relevant requirements and insurance coverage can be reviewed.

Routine contact method and expected response timeframe:
__________________________________________________

Urgent/off-schedule consultation procedure:
__________________________________________________

Backup supervisor or organizational contact during absence:
__________________________________________________

I do not provide continuous monitoring or guaranteed emergency availability. Do not delay necessary protective action while waiting for a response. Follow applicable workplace procedures, professional obligations, and local emergency arrangements.

11. Fees and cancellations

My fee is $225 for a full 60-minute individual supervision or consultation session, unless otherwise agreed in writing. Other durations, formats, taxes, and additional charges will be confirmed before booking.

Sessions end at the scheduled time. Late arrival generally does not extend the session or reduce the booked fee.

Payment is due at the end of the session unless otherwise arranged. The professional fee is waived for interns of The Compassion Project where included in their placement agreement.

Please provide at least 24 hours’ notice to cancel or reschedule. Any cancellation charge must be specified and agreed upon below.

Fee, applicable tax, and payer:
__________________________________________________

Late-cancellation/missed-appointment charge:
__________________________________________________

Report or administrative fees:
__________________________________________________

Reasonable advance notice will be provided for fee changes. Financial concerns will be discussed before discontinuing ongoing supervision.

12. Boundaries, conflicts, and disagreements

I recognize the power imbalance in supervision and aim to create a respectful environment for uncertainty, mistakes, and disagreement.

I will not undertake supervision of a former psychotherapy client. We will screen for overlapping relationships, including social relationships with your clients, and avoid arrangements that compromise judgment, confidentiality, or safety.

Where a proposed case involves my former client, we will address the conflict and appropriate express client consent before discussing case content. Independent supervision may be needed.

I will not request testimonials from current supervisees.

You may raise concerns verbally or in writing. We will clarify the issue and seek resolution, using independent consultation or an appropriate organizational process when necessary. You may approach the relevant professional body directly without first raising the concern with me.

13. Reviewing or ending services

Either party may request review of this agreement. Changes will be documented and agreed upon.

You may end services without an additional termination penalty. Agreed charges for booked appointments still apply.

If supervision is required for your practice, you must arrange replacement supervision before continuing work that requires it.

If I discontinue services, I will explain the reasons and provide reasonable notice and transition assistance where possible. We will address continuity of client care, outstanding evaluations, records, and any immediate safety or reporting obligations.

14. Contact and complaints

Pauline O’Brien, RP, CCC-S
paulineobrienrp@gmail.com
905-536-8830

CRPO: https://crpo.ca
416-479-4330 or 1-844-712-1364

BCACC: https://bcacc.ca
250-595-4448 or 1-800-909-6303

Complaint jurisdiction depends on the professional’s registration or membership and the matter involved. Providing BCACC’s contact details does not represent that I hold BCACC membership or ACS designation.

Agreement

We confirm that we have reviewed this agreement, completed the relevant arrangements, and had an opportunity to ask questions.

Supervisee/consultee name: __________________________

Signature: _____________________ Date: __________

Supervisor/consultant: Pauline O’Brien, RP, CCC-S

Signature: _____________________ Date: __________

Applicable addenda:
☐ Student placement
☐ BCACC supervision of supervision
☐ RP (Qualifying)
☐ CCPA-related supervision
☐ Other: __________________________________________

Addendum A: Student Placement Supervision

This addendum forms part of the Clinical Supervision and Consultation Agreement.

Student: ________________________________________

Institution/program: ______________________________

Placement site: __________________________________

Placement dates: _________________________________

Academic contact: _________________________________

Site/administrative supervisor: ______________________

Roles and coordination

We will clarify the responsibilities of the student, clinical supervisor, placement site, and institution, including clinical oversight, record custody, emergency coverage, evaluation, and communication.

Allocation of responsibilities:
__________________________________________________
__________________________________________________

Any teaching, grading, employment, or other overlapping role held by the clinical supervisor will be identified and assessed before proceeding.

Overlapping roles and safeguards:
__________________________________________________

Learning and evaluation

The institution’s required competencies and rubric will guide placement evaluation alongside applicable professional and client-safety standards.

Learning plan and required clinical activities:
__________________________________________________

Observation and review methods:
__________________________________________________

Evaluation dates, forms, and recipients:
__________________________________________________

Feedback will be ongoing. Concerns will be communicated early where possible, with a documented learning plan, review dates, and applicable institutional procedures.

Information sharing and concerns

Information routinely shared with the institution/site:
__________________________________________________

Student consent and other authority for sharing:
__________________________________________________

Process for disagreement, remediation, appeal, or supervisory rupture:
__________________________________________________

Urgent safety concerns may require action outside routine review processes.

Coverage and completion

Emergency and supervisor-absence arrangements:
__________________________________________________

Fees or placement fee waiver:
__________________________________________________

Process for placement interruption, transfer, or termination:
__________________________________________________

Student signature: __________________ Date: ______

Clinical supervisor signature: __________ Date: ______

Institution/site representative, where required:
_______________________________ Date: __________

Addendum B: BCACC Supervision of Supervision

This addendum applies only where the parties have confirmed that the arrangement meets the relevant BCACC program requirements. It supplements the core agreement and does not establish BCACC approval by itself.

Supervisor candidate: ______________________________

BCACC membership number: _________________________

Supervisor of Supervision: __________________________

Professional registration and supervisory designation:
__________________________________________________

Eligibility and program requirements

Before beginning, we will document the Supervisor of Supervision’s eligibility, including relevant education, supervisory designation or required BCACC pre-approval, experience, participation in supervision of supervision, and orientation requirements.

Evidence reviewed and any confirmation required:
__________________________________________________

Applicable BCACC pathway and requirements, checked on:
__________________________________________________

Schedule and qualifying practice

For the current standard ACS training pathway, the plan must accommodate:

• At least 100 hours of supervision provided during the applicable 12–24-month period.
• At least 18 hours of supervision of supervision during that same period.
• At least 12 individual hours, with up to 6 paired hours.
• At least 9 hours of direct supervision of supervision, with direct and indirect work planned in the required balance.
• No group supervision-of-supervision hours counted toward this training requirement.

The parties will confirm all additional program conditions and any changes before relying on hours.

Start/end dates and meeting schedule:
__________________________________________________

Candidate’s supervision practice and supervisee arrangements:
__________________________________________________

Direct observation/recording plan and indirect review methods:
__________________________________________________

Fees and cancellation terms:
__________________________________________________

Learning and oversight

We will assess fit between our supervisory philosophies, clinical approaches, and interpersonal styles.

The Supervisor of Supervision will provide oversight of the candidate’s supervisory practice, including individual and group work, developmental needs, ethical issues, evaluation skills, and client safety.

The candidate will prepare for meetings, maintain accurate records, disclose relevant supervisory concerns, maintain appropriate liability insurance, and obtain permissions needed for observation or recordings.

Learning objectives and competency criteria:
__________________________________________________

Consent and secure handling of supervisee/client material:
__________________________________________________

Feedback and evaluation

Work will include ongoing feedback, review of the candidate’s supervision agreement and professional disclosure, and review of the required supervision philosophy/reflection paper.

Materials, assignments, and review dates:
__________________________________________________

Final evaluation and submission arrangements:
__________________________________________________

Process for concerns, remediation, or disagreement:
__________________________________________________

Hours and competencies will be reported accurately. Payment or participation does not guarantee successful evaluation or ACS designation.

Candidate signature: ________________ Date: ______

Supervisor of Supervision signature:
__________________________________ Date: ________

Addendum C: Supervision for a Registered Psychotherapist (Qualifying)

This addendum forms part of the Clinical Supervision and Consultation Agreement. It establishes the arrangements for supporting an RP (Qualifying) in developing competence, meeting applicable CRPO requirements, and providing safe, ethical client care.

Supervisee: ______________________________________

CRPO registration number: __________________________

Practice setting: __________________________________

Supervisor: Pauline O’Brien, RP, CCC-S

Start date: ______________________________________

1. Registration and supervision requirements

Before beginning, we will review the supervisee’s registration status, applicable CRPO requirements, and any terms, conditions, limitations, or additional supervision requirements.

The supervisee agrees to use their professional title accurately and inform me promptly of changes to registration status or practice restrictions.

This agreement does not authorize practice beyond the supervisee’s competence or legal authority.

Requirements reviewed and date:
__________________________________________________

2. Initial assessment and learning plan

During our initial meetings, we will review:

• Education, clinical experience, and previous supervision.
• Current caseload, client populations, and therapeutic approaches.
• Areas of competence and areas requiring development.
• Assessment, consent, documentation, boundaries, and risk management.
• Available workplace support and emergency coverage.
• Learning preferences, accessibility needs, and professional goals.

We will develop a written learning plan with review dates.

Initial learning priorities:
__________________________________________________
__________________________________________________

3. Frequency and scope of supervision

We will agree on a regular schedule appropriate to the supervisee’s experience, competence, caseload, client complexity, and available supports.

Supervision frequency may increase when clinical risk, workload, unfamiliar interventions, or competence concerns require closer oversight.

Meeting frequency: ________________________________

Session duration: _________________________________

Format and platform/location: _______________________

Clinical work covered by this agreement:
__________________________________________________

Other supervisors and division of responsibilities:
__________________________________________________

4. Preparation and participation

The supervisee will prepare relevant case material and bring clinical, ethical, and safety concerns forward promptly.

Sessions may include case formulation, treatment planning, documentation review, therapeutic relationship issues, skills development, and review of clinical work using agreed methods.

The supervisee will discuss uncertainty, mistakes, complaints, adverse events, and difficulties following recommendations. Disagreement may be explored openly and does not remove either party’s professional obligations.

5. Client information and informed consent

The supervisee will explain the supervisory arrangement to clients, including the supervisor’s role and, where appropriate, identity, contact information, and the client’s ability to contact the supervisor.

Before sharing identifiable client information or recordings, the supervisee will obtain and document appropriate consent and follow the agreed secure-transfer arrangements.

Client disclosure and consent process:
__________________________________________________

Supervisor access to records or recordings:
__________________________________________________

6. Safety concerns and contact between sessions

Urgent concerns must not be held until the next scheduled supervision appointment.

The supervisee will follow the agreed escalation procedure, workplace policies, and applicable professional obligations. If I am unavailable, the supervisee will use the designated backup resources and take necessary protective action.

Urgent-contact procedure and response expectations:
__________________________________________________

Backup supervisor or organizational contact:
__________________________________________________

Emergency procedures:
__________________________________________________

7. Feedback and progress reviews

We will review progress against the learning plan regularly. Feedback will include strengths, areas for development, and any concerns affecting safe practice.

Where concerns arise, we will ordinarily document a learning or remediation plan, identify additional supports, and establish review dates. Protective action or reporting may be necessary where applicable obligations require it.

Progress-review dates: ______________________________

Evaluation methods: _______________________________

8. Supervision records and CRPO documentation

Both parties will maintain accurate supervision records. The supervisee will track clinical experience and supervision hours according to CRPO’s current requirements.

We will review logs periodically and resolve discrepancies promptly. I will complete attestations only for activities and hours I can substantiate.

CRPO determines whether requirements for registration changes or independent practice have been met. Completion of supervision, payment, or submission of an attestation does not guarantee a particular CRPO decision.

Log-review schedule and documentation deadlines:
__________________________________________________

9. Changes or ending supervision

We will review this arrangement when the supervisee’s caseload, practice setting, registration status, competence, or supervision needs change.

If supervision ends while the supervisee remains required to practise under supervision, appropriate replacement supervision must be arranged before continuing work that requires it.

We will document the end date, relevant transition arrangements, outstanding records, and any unresolved safety concerns.

Agreement

We confirm that we have reviewed this addendum and completed the arrangements relevant to the supervisee’s practice.

RP (Qualifying) signature: ___________________________

Date: __________________________________________

Supervisor signature: ______________________________

Date: __________________________________________

Addendum D: CCPA-Related Clinical Supervision

This addendum forms part of the Clinical Supervision and Consultation Agreement. Complete it where supervision is intended to support Canadian Counselling and Psychotherapy Association (CCPA) certification, professional development, or supervisor development. It does not replace CCPA’s official forms or establish approval of a particular arrangement.

Supervisee/candidate: __________________________________

CCPA membership and certification number, if applicable:
__________________________________________________

Supervisor: Pauline O’Brien, RP, CCC-S

Start date and review date: _____________________________

1. Purpose and eligibility

Identify the purpose before counting hours:
☐ Canadian Certified Counsellor (CCC) application or practicum-related requirement
☐ Ongoing professional development as a counsellor/therapist
☐ Canadian Clinical Supervisor (CCS) application or qualifying pathway
☐ CCS renewal or supervision of supervision
☐ Other: __________________________________________

CCPA currently uses the designation Canadian Clinical Supervisor (CCS) in its supervisor certification guidance. The supervisor’s existing credential is stated in the core agreement. Its current status and eligibility for the specific purpose will be checked before relying on this arrangement.

CCPA pathway, guide/form version, supervisor qualification requirements, and any written clarification obtained:
__________________________________________________
__________________________________________________

Requirements checked on: ______________________________

The requirements for CCC certification and CCS certification are different. We will not apply one pathway’s hour totals or definitions to another. CCPA makes the final recognition decision.

2. Ethics and cross-disciplinary practice

I will make my commitment to CCPA’s Code of Ethics and Standards of Practice explicit in our work. We will review those documents and the supervisee’s applicable professional code, standards, and legal obligations.

Where our professional disciplines or practice jurisdictions differ, we will clarify fit, competence, accountability, and any additional supervisory support needed.

Documents reviewed and relevant ethical considerations:
__________________________________________________

3. Learning and supervision plan

Learning goals, client population or supervisory work, and areas of competence to be developed:
__________________________________________________
__________________________________________________

Meeting frequency, duration, format, and platform:
__________________________________________________

We will distinguish observation or review of actual clinical/supervisory work from self-report, case discussion, role-play, or other indirect methods. Remote meetings alone do not determine the hour category. The applicable CCPA definitions will guide classification.

Direct observation or recording-review arrangements:
__________________________________________________

Indirect review methods and planned allocation of hours:
__________________________________________________

Client and, for supervision of supervision, supervisee permissions and secure handling arrangements:
__________________________________________________

4. Records and qualifying activities

Both parties will keep accurate records of dates, duration, format, activities, direct/indirect classification, feedback, and relevant learning needs. Logs will distinguish hours received, hours provided, and supervision of supervision.

Informal peer consultation is not automatically qualifying supervision. Where structured group work is proposed, we will verify the relevant requirements for leadership, structure, size, participation, and client disclosure before counting hours.

CCPA’s current CCS guidance allows some supervision-of-supervision activities to contribute to certification or renewal requirements. We will confirm how this applies to the candidate’s specific pathway rather than assuming BCACC and CCPA rules are interchangeable.

Agreed hour requirements, categories, evidence, and log-review schedule:
__________________________________________________
__________________________________________________

5. Evaluation and documentation

We will agree on feedback, competency review, and any formal report or reference before the work begins. Where actual supervision skills must be observed or evaluated, the plan must provide an appropriate opportunity to do so.

Evaluation methods, observation requirements, and review dates:
__________________________________________________

Official forms, references, recipients, deadlines, and consent to disclosure:
__________________________________________________

I will provide accurate documentation within my knowledge and the agreed scope. Participation or payment does not guarantee a favourable reference, certification, or acceptance of hours. Completing a supervision course alone does not establish a CCPA supervisor designation.

6. Fees, continuity, and agreement

Fees, cancellation terms, confidentiality, emergency arrangements, dispute resolution, and termination follow the core agreement unless varied below.

Additional or different arrangements:
__________________________________________________

We will review this plan if CCPA requirements or the candidate’s status change. Required official forms must still be completed separately.

Supervisee/candidate signature: __________________________

Date: __________________________________________

Supervisor signature: _________________________________

Date: __________________________________________