Sample Supervision Agreement

Jay Mills, Ph.D,, being a licensed psychologist with expertise in treating children, do
hereby agree to supervise, Samuel Knapp, Ed.D., starting on August 1, 2013 to July 31,
2014 for the purpose of getting supervision needed to qualify to become licensed as a
psychologist in the State of Pennsylvania.
I am qualified as the supervisor as I have no current disciplinary complaints against me
and I am qualified in the area in which I am supervising Dr. Knapp. There is no dual
relationship that would prohibit this supervisory relationship.
Dr. Knapp will be hired as an independent contractor and will receive 40% of all
revenues generated from his professional work which will include psychological and
psychoeducational assessments, vocational assessments, and counseling and
psychotherapy. He will purchase his own malpractice insurance. Office space and
secretarial assistance will be provided consistent with agency policy. Dr. Knapp will
disclose his trainee status to all clients/patients.
Dr. Knapp agrees to work an average of 40 hours a week for one year. The agency
policies on vacation, sick leave, and holidays will apply.
Dr. Knapp agrees to adhere to the APA Ethics Code, APA standards and guidelines, and
standards of the Pennsylvania State Board of Psychology, and all office policies. Dr.
Knapp agrees to inform the supervisor of all relevant information obtained in assessment,
counseling or therapy related to patient welfare including aggressive or suicidal ideation,
serious threats to property, suspicions of child abuse, or other circumstances likely to
harm patients or third parties. Documentation will be in accordance with agency policies
and state and federal laws. All records will belong to the agency upon the termination of
this agreement.
As supervisor, I agree to adhere to the Standards of the State Board of Psychology for
post-doctoral supervisees and to complete the requirements and forms necessary for Dr.
Knapp to become licensed as a psychologist in Pennsylvania. This includes two hours of
face to face supervision by myself (or 1 hour by myself and 1 hour by a delegated
supervisor to be named), I will provide learning opportunities that will meet the standards
of the State Board of Psychology and provide quarterly evaluative reports consistent with
those requirements. Remedial work, if any, will be discussed early and Dr. Knapp will be
given the opportunity to correct any deficiencies.
Either party has the right to terminate this agreement given two weeks notice, except that
Dr. Knapp may be dismissed for cause including a breach of the APA Ethics Code, the
regulations of the State Board of Psychology, or agency policies.