CLINICAL SUPERVISION DIARY NOTE

RISE UP Process + Proctor’s Functional Model • Confidential Professional Record

1. Session Details

Date:

Session No:

Supervisee:

Supervisor:

Duration:

Mode:

Individual Group Session recorded Recording waived by agreement

2. Confidentiality & Consent

This supervision is confidential subject to the limits set out in the Clinical Supervision Agreement (risk of serious harm, mandatory reporting, professional body requirements, and where the Supervisor also holds organisational/line-management responsibilities). Client identity is protected wherever practicable.

Confidentiality limits reviewed / confirmed this session

3. RISE UP Session Structure

R – Review (previous commitments, insights, agreed actions)

I – Issues (key cases, practice concerns, developmental needs brought today)

S – Supervisee (wellbeing, confidence, professional growth, restorative focus)

E – Ethics (ethical, legal, professional standards, boundaries, dual relationships, documentation)

U – Unfinished business (matters carried over or left unresolved)

P – Planning (goals, strategies, actions, next steps)

3A. RISE UP Scoring Rubric

Rate the quality of coverage and supervisee engagement for each RISE UP component in this session. Use the scale below. Ratings support developmental tracking and are not a pass/fail assessment of the supervisee.

RISE UP Component	1 Minimal	2 Limited	3 Adequate	4 Strong	5 Excellent	N/A
R – Review Follow-through on prior actions & insights
I – Issues Clarity & depth of issues brought
S – Supervisee Reflective capacity & restorative engagement
E – Ethics Ethical awareness & professional standards
U – Unfinished Recognition & management of open issues
P – Planning Clarity & usefulness of forward plan
Overall Session Quality Integration of process, alliance & outcomes

Scale guide: 1 Minimal – Component largely absent or superficial | 2 Limited – Addressed briefly / low depth | 3 Adequate – Covered sufficiently for purpose | 4 Strong – Clear, reflective, useful depth | 5 Excellent – Highly integrated, insightful, actionable

Rubric notes / developmental observations:

4. Proctor Domains Addressed this Session

Formative (Educational / Skills) Normative (Managerial / Ethics / Quality) Restorative (Supportive / Wellbeing)

Primary domain emphasis:

5. Risk, Safety & Escalation

No significant risk issues identified Risk / safety issue discussed Escalation / further action required

6. Agreed Actions & Follow-up

Next session:

Focus for next:

7. Additional Professional Notes

8. Supervisor Confirmation & Signature

I confirm this note is an accurate record of the supervision session conducted under the RISE UP process and Proctor’s Functional Model. A copy of relevant actions / notes will be provided to the Supervisee as agreed.

Supervisor Electronic Signature

Name:

Date:

Supervisee Acknowledgement (optional)

Name:

Date:

This diary note forms part of the professional supervision record. It is not a client clinical note. Retain in accordance with professional and organisational record-keeping requirements. Supervisors remain responsible for the accuracy and completeness of their own records for ACA / PACFA membership purposes.