Report of Releasing Supervisor for Associate Sex Offense Service Provider (ASOSP) 
This form is required for any termination of supervision, whether it be due to a change in supervisor or the completion of the supervision process for the ASOSP. This form must be completed and signed by the Credentialed Sex Offense Service Provider (CSOSP). The CSOSP should send this form directly to the SOMB and any applicable Agency.

Date of Form __________________________________________________________________________
ASOSP Name __________________________________________________________________________  
ASOSP Provider Number _________________________________________________________________
CSOSP Supervisor Name _________________________________________________________________   
CSOSP Supervisor Provider Number ________________________________________________________
Practice Address _______________________________________________________________________
_____________________________________________________________________________________

Summary of Supervision
1)	Supervision state date ___________________ Supervision end date ______________________
2)	I provided professional services in the same work setting where the ASOSP gained supervised professional experience. Yes _____ If no, please explain in detail. _________________________
3)	I have provided 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. ___________________________________________________________
4)	I have provided ____________ hours of individual supervision to the ASOSP during my supervision of them. 

Summary of Work Experience 
5)	The ASOSP conducted____________ hours of clinical services during my supervision of them.
6)	Please mark all responses that apply. The ASOSP conducted: Individual therapy ______
Group therapy ______ Family therapy ______ Evaluations ______ Professional consultation ______ Professional training ______

Supervisory Review of ASOSP
7)	The ASOSP’s clinical judgement is: Poor ______ Needs improvement ______ Acceptable ______ Better than average ______ Outstanding ______
8)	The ASOSP’s documentation/clinical writing is: Poor ______ Needs improvement ______ Acceptable ______ Better than average ______ Outstanding ______
9)	The ASOSP’s professionalism is: Poor ______ Needs improvement ______ Acceptable ______ Better than average ______ Outstanding ______
10)	The ASOSP’s professional ethics are: Poor ______ Needs improvement ______ Acceptable ______ Better than average ______ Outstanding ______
11)	The ASOSP’s use of supervision is: Poor ______ Needs improvement ______ Acceptable ______ Better than average ______ Outstanding ______
12)	Reason for termination of supervision _______________________________________________
______________________________________________________________________________ 

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 ____________________