Registration Form

Please complete the form below.

  • Please upload a copy of your current professional license.
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  • Terms and Conditions for Individual and Group Supervision

    As a participant in the County of Summit (“Akron”) CBT Training and Supervision project, I agree to the following terms and conditions:

    I will comply with the requirements of the Federal Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and the corresponding HIPAA regulations related to the confidentiality and security of medical information

    I have attached a copy of my current license to practice. I will maintain a current license and liability insurance and inform Beck Institute immediately of any changes in the status of my license or insurance.

    I understand that supervision received is to be construed only as providing a theoretical foundation for my practice of cognitive therapy, and not as protection against lawsuits brought against me in the course of my practice. I agree to hold harmless Beck Institute and my Beck Institute appointed supervisor.

    I will obtain written permission of any clients I intend to audio-record for the purpose of supervision using the approved Consent to Record form that I have been provided by my agency and I will not use the client’s name when naming the session recording file. This permission will include written consent to share the audio-recording with the Beck Institute.  I will comply with the Ohio – Counselor, Therapist, and Marriage & Family Board – Standards of Ethical Practice & Professional Conduct including but not limited to OAC 4757-5-02 and OAC 5122-29-03 concerning patient privacy.

    I will be given access to the Beck Institute file sharing portal. I will deliver client session recordings to pre-approved parties (identified as my appointed Beck Institute supervisor and, if in a supervision group, my assigned group members) using only this portal. I will use the portal for the scope of my supervision only and will not use it for any other purpose.

    I will deliver session recordings to the pre-approved parties at least three days prior to my scheduled supervision session, including the first supervision session.

    I understand that my session recordings will be rated by my appointed supervisor using the Cognitive Therapy Rating Scale (CTRS) and that my scores may be used in future Beck Institute research projects, with no identification of client or therapist.

    I understand that if my session exceeds 50 minutes, the pre-approved parties with whom this session is shared will only listen to the first 50 minutes of the session and any rating I receive will be based only on the first 50 minutes of the session.

    I understand that session terms are defined as follows:

    • 1st Term: 10 sessions, to take place approximately weekly, between July 1 and September 30, 2017.
    • 2nd Term: 10 sessions, to take place approximately weekly, between October 1 and December 31, 2017.

    FURTHER, IF ENROLLED IN INDIVIDUAL SUPERVISION (one-on-one supervision between me and my appointed supervisor):

    I understand that, in order to be eligible for a certificate of completion in the Beck Institute supervision program for Individuals by the conclusion of my 1st Term, I will need to:

    • Attend all ten scheduled 45-minute long supervision sessions
    • Submit at least 7 session recordings
    • Receive at least three CTRS scores of 40 or above on my session recordings
    • Receive a positive evaluation from my appointed supervisor

    I understand that if I fail to meet the above requirements, I will receive a letter of participation in the program.

    I understand that, in order to progress to Supervision of Supervision for Individuals for my 2nd Term, I will need to:

    • Successfully complete my first term as outlined above
    • Receive at least three CTRS scores of 50 or above on my session recordings
    • Receive the recommendation of my appointed Beck Institute supervisor

    I understand that if I do not meet the above requirements for supervision of supervision, my second term will be a continuation of my first term.

    FURTHER, IF ENROLLED IN GROUP SUPERVISION (supervision between me, 2-3 other County of Summit clinicians and our appointed Beck Institute supervisor):

    I understand that I am currently scheduled for the 1st Term of Supervision only. I must attend at least eight of ten scheduled 60-minute long supervision sessions throughout this term. Group members will rotate submission of session recordings and I will be responsible to submit at least two and possibly three session recordings throughout the term. If I meet these requirements, I will receive a Letter of Participation in the program.

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