Clinical Supervision Form

Helps supervisors evaluate a case manager's performance and record recommendations from the supervision session.

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Date

Time of Supervision

Supervisor Name

First Name

Last Name

Case Manager Name

First Name

Last Name

Was the employee present and on time for all shifts/appointments?

Yes No

Were there any incidents involving the employee? If yes, please describe in additional Comments below.

Yes No

Do you communicate with peer coaches on an appropriate basis?

Yes No

Are you handling documentation in an appropriate manner? (Documenting assessments, document phone calls to peers, etc)

Yes No

Do you have any concerns related to peer coaches?

How many assessments did you schedule this week?

How many assessments did you complete this week?

Supervisor's recommendation to Case Manager.

Rate the quality of work of the Case Manager (1-10, 1-Unsatisfactory/10-Exceeds Expectations)

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