This application outlines the process for Central Oregon Behavioral Health Consortium (COBHC) member sites to request reimbursement for the cost of licensed clinical supervision for masters-level student interns, up to the standard rate of $150 per hour. COBHC has limited funds to support the expansion of clinical supervision to host masters level student interns at COBHC member sites. The member site is responsible for contracting with a qualified clinical supervisor and maintaining day-to-day oversight of the intern. The member site must provide East Cascades Works (EC Works) with a copy of the signed supervision contract and proof of payment prior to reimbursement.

EC Works will reimburse COBHC member sites for licensed clinical supervision provided to masters-level student interns, up to the approved contract amount. The grantor for this service requires that EC Works prioritizes funding for supervisees working in rural and underserved communities in Crook, Deschutes, and Jefferson counties.

If you are unable to find a clinical supervisor, you may contact the EC Works Business Services Program Manager to explore potential connections to qualified candidates; however, there is no guarantee of availability, and your site remains responsible for securing the supervisor.
Eligibility Requirements (All Must Be Met to Qualify)

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* 1. Please confirm that your organization meets the following criteria:
  • We are a current, dues-paying member of COBHC.
  • Our organization’s license is current and in good standing with the appropriate state licensing board (if applicable).
  • We have identified a qualified clinical supervisor who meets state requirements (e.g., LCSW, LPC, LMFT, Psychologist) who will provide licensure supervision for our supervisee(s) or we will work with EC Works to access qualified clinical supervision candidates.

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* 2. Name of Organization:

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* 3. Address:

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* 4. Phone:

Summary of Reimbursement Request

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* 6. Total number of interns:

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* 7. Total number of supervisors:

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* 8. Total number of hours contracted:

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* 9. Total request amount, based on the standard rate of $150/hour per student/intern supervised.

Supervisee Management and Support

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* 10. Who will serve as the site supervisor for the supervisee, what are their credentials, and what is their role in day-to-day oversight?

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* 11. How will your organization provide regular feedback, mentorship, and performance guidance to the supervisee outside of clinical supervision?

Selecting and Coordinating with the Clinical Supervisor

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* 12. What are the qualifications and experience of the clinical supervisor that ensure an appropriate fit for your supervisee’s clinical learning needs and internship experience? Please provide verification or attestation that the qualified clinical supervisor or organization meets state requirements to provide masters-level intern supervision.

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* 13. How will you ensure supervision hours and documentation provided by the clinical supervisor align with masters-level student intern supervision requirements? What is your plan for maintaining regular communication with the clinical supervisor regarding supervision requirements?

Supervisee Work Context

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* 14. What type of work will the supervisee(s) be performing at your site and how will you collaborate with the supervisee(s) to align this work with their supervision plan?

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* 15. Will the supervisee(s) be serving clients in rural or under-resourced communities? If yes, how will your organization support them in navigating these service contexts? Please specify the address from where the supervisee will be interning.

Collaboration with EC Works

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* 16. Does your organization have a structure in place to provide timely updates, reports, and documentation as required for reimbursement? How will the site communicate with EC Works any changes or issues addressed?

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* 17. Please upload your executed contract with the clinical supervisor, if available. A signed supervision contract must be provided prior to receiving reimbursement.

Sign and Date

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* 18. Signature

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* 19. Date:

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