Notice of Master Social Work Intern
Peaceful Pastures Therapy works closely with Saint Leo University preparing masters level social work interns through working with clients.
This form provides understanding and acknowledgment that you will either be receiving services from a social work intern that is overseen closely by a licensed clinical social worker or have an intern student shadowing the supervisor during a session as a silent observer. We are a teaching facility preparing new therapists learning psychotherapy.
Students understand and adhere to all HIPAA compliant practices and will maintain your confidentiality at all times.
There will be times the supervisor will sit in on sessions and will frequently review the treatment plan.
If there are any questions or concerns at any time, the overseeing supervisor is available to speak with you.
PLEASE NOTE; You have the right to withdrawal consent of shadowing at any time and will always be verbally asked prior to session.

Supervisor:
Jessica Oliver, LCSW
(813) 449-2500
jessica@peacefulpasturesranch.org

By acknowledging this form and signing your name, you understand and agree to this.

Thank you for supporting the education of therapists.
Sign in to Google to save your progress. Learn more
Email *
Today's Date *
MM
/
DD
/
YYYY
Name of client *
Do you consent to having a student shadow your sessions? *
By typing my name in the field below I attest to the above. My typed name shall serve as my signature. *
Relationship to client if a minor *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Peaceful Pastures Ranch. Report Abuse