Application for Initial (or New) Supervision for Associate Sex Offense Service Provider (ASOSP) 
This form is required for any initial supervisor or change in supervisor for the ASOSP. This form must be completed and signed by the prospective Credentialed Sex Offense Service Provider (CSOSP). The CSOSP should give this form to the ASOSP applicant for their submission to the SOMB in addition with their other application materials. 

Date of Form __________________________________________________________________________
ASOSP Applicant Name __________________________________________________________________  
ASOSP Applicant Provider Number (if applicable) _____________________________________________
Prospective CSOSP Supervisor Name _______________________________________________________   
Prospective CSOSP Supervisor Provider Number ______________________________________________
Practice Address _______________________________________________________________________
_____________________________________________________________________________________

Supervision Information
1)	I will be providing professional services in the same work setting where the ASOSP applicant is gaining supervised professional experience. Yes _____ If no, please explain in detail on a supplemental page. 
2)	Anticipated start date of supervision ________________________________________________
3)	Estimated number of weekly clinical hours for the ASOSP applicant under my supervision _____  
4)	I will be providing at least 1 hour of individual and face-to-face supervision, either in person or through video technology, for every 10 hours of clinical work for the ASOSP. Yes _____ If no, please explain in detail how adequate supervision will be provided on a supplemental page.
5)	I am currently supervising the following ASOSP(s): 
1.	________________________________________________
2.	________________________________________________
3.	________________________________________________
4.	________________________________________________
6)	I understand that I am required to inform all of the ASOSP applicant’s clients that they are being treated by an ASOSP.  Initial________
7)	I recognize that the ASOSP will working under my credential as a CSOSP and I accept direct responsibility for supervising them. I understand that I am accountable for the service provided under my credential. Initial_______
8)	Please attach a description of the ASOSP applicant’s anticipated SOSP-related clinical work. This description must be signed by both the ASOSP applicant and the CSOSP Supervisor. The description must include the following: 
a)	An outline of the expected specific clinical duties of the ASOSP.
b)	A description of the limits of independent action and decision-making for the ASOSP. 
c)	The format of supervision, including the ratio of clinical hours to supervisory hours. 
d)	Set forth a detailed emergency and contingency plan that describes the ASOSP’s plan of action in time of clinical crisis and includes prearranged emergency consultations and mechanism for obtaining these consultations.
e)	Describe a backup plan for the anticipated or unanticipated unavailability of the CSOSP, as they will remain accountable for the actions of the ASOSP even when they are unavailable.
I hereby acknowledge that I have read Regulation 1100 from the Delaware Administrative Code for the Delaware Sex Offender Management Board (SOMB) pertaining to the supervision of ASOSPs. I further swear or affirm that the information contained in this form is correct and I understand that any intentionally fraudulent information will be reported to the SOMB and may result in disciplinary action. I also recognize that additional clarification may be requested by the SOMB.

CSOSP Signature ___________________________________________ Date ____________________