Supervisee Services Agreement

Island Clinical Supervision

Last updated: April 2026

Applies to all licensure tracks: LMFT, LMHC, LCSW

This Agreement is entered into between Island Clinical Supervision LLC ("ICS"), a Hawaii limited liability company, and the supervisee identified at account creation ("Supervisee"). It governs the clinical supervisory relationship, participation expectations, scheduling, fees, confidentiality, and all other terms of service across all licensure tracks offered by ICS.

1. Purpose and Scope of Supervision

The purpose of this Agreement is to facilitate the Supervisee's attainment of the applicable Hawaii clinical license by providing qualified, ethical, and structured clinical supervision. ICS services are designed to:

• Ensure compliance with Hawaii licensure requirements governing pre-licensure supervised clinical experience.
• Promote the professional development, clinical competency, and ethical practice of the Supervisee.
• Protect the welfare of clients served by the Supervisee throughout the supervisory period.

2. Licensure Track Requirements

Supervision requirements differ by licensure track. The requirements applicable to the Supervisee are determined by the track selected at enrollment. All three tracks share the following general supervision formats:

• Individual supervision (one supervisor, one supervisee)
• Group supervision (one supervisor, up to six supervisees per session)
• Telehealth and remote supervision are permitted under current Hawaii regulations, provided confidentiality standards are maintained.

The track-specific requirements are as follows:

Supervisees are responsible for verifying current licensure requirements directly with their applicable Hawaii licensing board. ICS provides supervision services intended to support licensure progress but does not guarantee that any specific hours or formats will satisfy board requirements.

3. Roles and Responsibilities

ICS Responsibilities

• Assign a qualified, Hawaii-licensed supervisor appropriate to the Supervisee's licensure track.
• Provide a structured supervision plan tailored to the Supervisee's hours, goals, and clinical needs.
• Maintain accurate records of supervision hours, session content, and Supervisee progress.
• Provide timely documentation required for licensure applications upon request.
• Ensure all supervision meets the standards set forth by the Hawaii Department of Commerce and Consumer Affairs (DCCA) and the applicable licensing board to whatever extent possible.
• Notify the Supervisee of any change in supervisor assignment with reasonable advance notice.

Supervisee Responsibilities

• Maintain current, valid Hawaii prelicensure registration or trainee status as required by law throughout the supervision period.
• Attend all scheduled supervision sessions punctually and prepared.
• Provide accurate case presentations and self-assessments as requested by the supervisor.
• Practice only within the scope of the Supervisee's training, competence, and prelicensure status.
• Adhere to all applicable ethics codes and Hawaii law for the selected licensure track.
• Immediately report to the supervisor any ethical concerns, client safety issues, or incidents requiring consultation.
• Track and maintain personal records of all supervised hours in addition to ICS records.
• Pay all supervision fees as outlined in this Agreement.

Supervisor Responsibilities

• Maintain an active, unrestricted Hawaii license in the applicable discipline throughout the supervisory relationship.
• Provide competent, ethical supervision consistent with professional standards and Hawaii law.
• Conduct supervision in a manner that prioritizes client welfare above all other considerations.
• Provide timely, constructive feedback and professional development guidance.
• Complete and sign all required supervisory documentation accurately and promptly.

4. Supervision Approach

Prior to or at the commencement of supervision, the parties will collaboratively develop a supervision plan that addresses:

• The Supervisee's current clinical experience, strengths, and areas for growth
• Specific learning objectives and competencies to be developed
• Agreed-upon supervision modality, frequency, and schedule
• Anticipated distribution of individual versus group hours
• Caseload parameters and client population focus
• Evaluation schedule and criteria

This plan will be reviewed and updated at minimum every six months, or upon any significant change in the Supervisee's clinical setting or goals.

5. Fees and Payment

Supervision fees are established in accordance with ICS's current fee schedule for the applicable tier and track. Fees are communicated to the Supervisee in writing prior to the commencement of services.

• Individual and group session fees are per the ICS fee schedule for the selected tier.
• Payment is due at the beginning of each month's commitment and is collected automatically with a credit card on file.
• A fee schedule addendum (Exhibit A) is attached to and incorporated into this Agreement.

ICS reserves the right to adjust fees with 30 days' written notice to the Supervisee. Supervisees who are unable to afford current fees are encouraged to contact ICS to discuss available tiers or scheduling options.

6. Scheduling and Attendance

Supervision sessions are scheduled by mutual agreement of the Supervisee and the assigned supervisor. The following attendance policies apply:

• Supervisees must provide a minimum of 24 hours' advance notice to cancel or reschedule a session.
• Sessions cancelled with less than 24 hours' notice may be charged a late cancellation fee per the fee schedule.
• No-shows without advance notice of at least 24 hours will be charged the full cancellation fee to the card on file.
• Habitual late cancellations or no-shows may be grounds for termination of this Agreement.
• ICS will make reasonable efforts to reschedule sessions cancelled by the supervisor within the same billing period.

7. Documentation and Records

ICS will maintain supervision logs documenting, at minimum: the date, duration, modality, participants, and general content of each supervision session. The Supervisee acknowledges and agrees that:

• Supervision records are maintained by ICS and are subject to applicable state and federal confidentiality requirements.
• Supervision records do not constitute the Supervisee's clinical records and are separate from any client records.
• Supervisees can monitor their hours and progress in their account at any time.

8. Confidentiality

All clinical material shared during supervision is confidential. The following exceptions apply:

• Client identifying information will not be disclosed outside the supervisory relationship without written consent, except as required by law.
• The supervisor is a mandated reporter under Hawaii law and may disclose information to protect clients or third parties from imminent harm.
• ICS may consult with legal or ethics advisors on matters arising from supervision, using the minimum information necessary.

The Supervisee is responsible for obtaining any necessary client consent for the use of session materials in supervision, consistent with applicable ethics codes and Hawaii law. ICS confidentiality standards are governed by HIPAA and 42 CFR.

9. Scope of the Supervisory Relationship

This Agreement establishes a professional supervisory relationship only. It does not:

• Create an employment relationship between ICS and the Supervisee.
• Create a therapeutic relationship between the supervisor and the Supervisee.
• Authorize the Supervisee to represent themselves as licensed or to practice beyond the scope of their prelicensure status.
• Guarantee licensure, employment, or any particular professional outcome.

The Supervisee understands that the supervisor is available for clinical consultation within scheduled sessions. For clinical emergencies, the Supervisee should follow their employer's established emergency protocols and contact the supervisor at the earliest reasonable opportunity. ICS is not a crisis response forum.

10. Evaluation and Remediation

The supervisor will conduct formal evaluations of the Supervisee's clinical competence and professional development at intervals specified in the supervision plan. If concerns regarding competence, professional conduct, or client welfare are identified:

• The supervisor will communicate concerns to the Supervisee in writing with specific, actionable feedback.
• A Remediation Plan may be developed, outlining specific goals, timelines, and success criteria.
• ICS reserves the right to suspend or terminate supervision if remediation efforts are unsuccessful or if client welfare is at risk.
• The Supervisee may appeal any adverse determination in writing to ICS within 10 business days.

11. Term and Termination

This Agreement is effective as of the account creation date and will continue until the earlier of: (a) attainment of the applicable license, (b) mutual written agreement to conclude supervision, or (c) termination by either party.

11.1 Voluntary Termination

Either party may terminate this Agreement with 30 days' written notice. During the notice period, supervision will continue unless otherwise agreed.

11.2 Immediate Termination

ICS may terminate this Agreement immediately and without prior notice if:

• The Supervisee engages in conduct that poses a risk to client welfare or safety.
• The Supervisee violates applicable ethical codes or Hawaii law.
• The Supervisee misrepresents their licensure status, clinical hours, or other material information.
• The Supervisee fails to maintain required prelicensure registration or trainee status.

11.3 Post-Termination

Upon termination, ICS will provide the Supervisee with a summary of all supervised hours completed under this Agreement within 30 days of the termination date.

12. Limitation of Liability

ICS and its supervisors are not responsible for the independent clinical decisions or actions of the Supervisee. The Supervisee is responsible for maintaining appropriate professional liability insurance throughout the supervisory period. ICS strongly recommends that supervisees maintain active professional liability coverage at the student, trainee, or associate level with a minimum of $1,000,000 per occurrence and $3,000,000 aggregate.

To the extent permitted by Hawaii law, ICS's liability under this Agreement shall not exceed the total fees paid by the Supervisee in the six months preceding any claim.

13. Dispute Resolution

The parties agree to attempt to resolve any dispute arising from this Agreement through good-faith negotiation. If direct negotiation fails, the parties agree to attempt mediation before pursuing any other legal remedy. This Agreement shall be governed by the laws of the State of Hawaii. Any legal proceedings shall be brought in the appropriate courts of the State of Hawaii.

14. Entire Agreement and Amendments

This Agreement, together with any attached exhibits, constitutes the entire agreement between the parties regarding clinical supervision services and supersedes all prior oral or written understandings. This Agreement may be amended only by a written document signed by both parties. In the event of conflict between this Agreement and any exhibit, this Agreement controls unless the exhibit expressly states otherwise.

15. Acknowledgment

By creating an account, completing enrollment, or checking the acceptance box during the checkout process, the Supervisee confirms that they have:

1. Read and understood this Agreement in its entirety.
2. Had the opportunity to ask questions and seek clarification.
3. Received or been directed to ICS's current fee schedule (Exhibit A).
4. Reviewed the applicable Hawaii licensure requirements for their selected track.
5. Understood that supervision does not guarantee licensure and that meeting all requirements is ultimately the Supervisee's responsibility.

Electronic acceptance during account registration or checkout constitutes a binding signature for purposes of this Agreement.

On behalf of Island Clinical Supervision LLC: Heather Pierucki, LMHC, Managing Member  ·  heather@changeworkshawaii.com

This page is the permanent published version of the Island Clinical Supervision Supervisee Services Agreement. Questions may be directed to heather@changeworkshawaii.com.