ON-LINE SUPERVISION PROGRAM AGREEMENT

I have read and understand all of the on-line supervision program components and agree to maintain full confidentiality and professional responsibility as outlined in the on-line supervision program description.

Please print and sign this agreement.

On-Line Supervision Program Agreement
Last Name:		First Name:
Street address:
email address:
Confidentiality: All aspects of counseling, such as intake information, assessment date, verbal/written records, and/or any other relevant client information is considered confidential. Further, I am aware of the limits of confidentiality and follow all legal and professional association guidelines. I attest that I have obtained appropriate levels of consent (client and agency) to share client sensitive information during on-line supervision.
Phone number
Signature:			Date:
Method of Payment Please check one
Visa		Mastercard
Card Number:			Expiry Date:
Cardholder Signature:

Please mail or fax this form. to:
Rocky Mountain Play Therapy Institute
1318-15th Avenue S.W. Calgary AB T3C 0X7
or Fax: 403 245-4137

You will be notified, via e-mail, within 48 hours of receipt of payment.