THM Clinical Supervisor Externship – INSTITUTE OF TRADITIONAL MEDICINE

THM Externship

Please complete and submit this form prior to beginning your Supervision of an ITM Intern Externship

***Please put this email on your 'safe list' to receive emails from ITM regarding this Externship: info@itmworld.org

Clinical Supervision involves the mentorship, education, oversight and ongoing assessment of a Herbal Student's practice and learning by a Clinical Supervisor to ensure that the Herbal Student is developing the skills and growth at the expected standard of knowledge and care and that client safety is not being compromised.

Before submitting this form, please ensure you have reviewed the Externship Document Provided by the Intern.

Supervisor Name *

First

Last

Email *

Phone *

Intern Name *

First

Last

Which Term are you providing Supervision? *

Fall
Winter
Spring
All Terms in Year 2

What is the method of Supervision *

In-Person on-site location
Online - via Zoom
Combination of in-person/online

Do you currently have insurance (General Liability/Malpractice - errors/omissions)? *

Yes
No

Have you met with the Intern to review requirements for the Externship? *

Yes
No
No, will complete prior to Externship commencement

Are you related to the Intern in any way or is there any reason why you cannot be objective in your supervision of this Intern? *

Yes
No

Are you aware of any potential, or what could be perceived as a potential, conflict of interest with the Intern? *

Yes
No

If Yes, please explain...

Are you aware of any past or current disciplinary or incapacity claims or proceedings against you? *

Yes
No

If Yes, please explain...

Do you have a minimum of five consecutive years of independent practice within the scope of practice to be supervised? *

Yes
No

Do you currently have insurance coverage for Interns if providing onsite clinical internship? *

Yes
No
No, will purchase prior to Externship

Location of Externship if In-Person Onsite (or Location of Supervisor Clinic) *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please list the Supervision Arrangements (including schedule of meeting, number of hours, in-person/online, how records/feedback will be maintained/logged) *

Please list the Supervision Content/Expectations (what will you provide in the Supervision Role - ex case study review, formula building, practical skills, theoretical education) *

Declaration (copy) *

Agreed

By checking this box and submitting this Clinical Supervision form, I acknowledge and agree to the following: That the internship details above are true and accurate. I agree that I have reviewed the Externship Document and meet all the requirements to be a Clinical Supervisor for Externships for an ITM Intern. I understand that the Intern is responsible for uploading copies of any case studies completed (and that if they were completed with one of your personal clients, that the client has been notified of this) Declaration: I hereby attest that all statements on this application form are true and complete in all respects, and no relevant information has been withheld.

Declaration *

Agreed

By checking this box I acknowledge and agree to the following: That upon completion of the Supervision I will provide ITM with a detailed Assessment using the ITM Clinical Supervision forms of the Intern's progress and internship. I will provide a detailed and honest summation of the Internship including hours, content and assessment.

Waiver *

Agreed

By checking this box and submitting this application/registration I acknowledge and agree to the following: I, the participant release the organizers of the Institute and their directors, sponsors, employees and agents from any liability for death, disability, injury and property damage. The participant acknowledges the risks involved with participating as a Clinical Supervisor for the Intern and assumes all responsibility, and waives any claims they may have. I acknowledge and agree that I am not an Employee of ITM nor a Contractor and no renumeration will be exchanged between ITM and myself as the Clinical Supervisor.