ACP Supervision Contract: trial form

ACP Supervision Contract

Annual contract for candidates to complete
  • This is the annual contract for all Provisional Members to complete who are undertaking the ACP. Fill in this form to update your yearly supervision details. An asterisk denotes a required field.
  • NOTE: This form is private and can be viewed by you alone online. It is securely stored once it has been submitted
  • Please note: Your time-frame starts from the date of your Initial Panel acceptance onto the ACP pathway.
  • Click the plus icon to add a line for each year of your supervision
    YearHours Supervised 
    Add a new row
  • I have reviewed the Supervision and Advanced Clinical Practice Policy and Procedures documents on the website at and I agree to follow the Association’s Code of Ethics. I hereby contract to meet weekly for the next year at an agreed fee.
  • If there has been a complaint or criminal charge against you, your supervisor must be informed.
  • Tick the box as to whether you are or are not registered
  • Note: You are not entitled to use the term psychotherapist unless you hold registration with PBANZ.
  • If you are registered, please give your scope of practice
  • [FOR THE SUPERVISOR: after the supervisee ticks the box below, the form is sent to you automatically. When you are ready to complete your part of the form, click on this link]: