Step 1 of 4 25% Date(Required) MM slash DD slash YYYY Type of Supervision(Required)14-day Staff Supervision30-day In-Home Parent SupervisionGroupLocation:(Required)OfficeHomeSession Start Time:(Required) Hours : Minutes AM PM AM/PM Duration of Session:(Required)30 min45 min1-hourDEMOGRAPHIC INFORMATIONConsumer Name:(Required) First Last Parent/Guardian Name:(Required) First Last Staff Name:(Required) First Last Person conducting session:License Type(Required) Consumer Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code GROUP SUPERVISIONStaff Members:(Required)Notes from Supervision:(Required) Staff Being Supervised:(Required) First Last DRA(s) Reviewed:(Required)Areas/Issues Addressed:(Required)Training/Core Behavioral Principles Addressed:(Required)Intervention/Observations:(Required) Clinician Signature:(Required)I attest that the information provided is true to the best of your knowledge. Clinician Email:(Required) Type of session:(Required)VirtualIn-PersonVIRTUALUnder current COVID-19 telehealth standards, services can be provided via phone or video.Permission for this session:(Required)Approval for this session was provided verbally.Approval for this session was NOT provided verbally.IN-PERSONStaff Signature:(Required)I attest that the information provided is true to the best of your knowledge. Parent Signature:(Required)I attest that the information provided is true to the best of your knowledge.