NEW LPC-S Form

1
Name
First Name
Last Name
2
Phone Number
Please enter a valid phone number.
3
Email
example@example.com
4
What type of supervision are you seeking?
for LPC only
For RPT only
For both LPC and RPT
LPC for now, RPT in the future
5
Which of the following are you Supervision mediums are you seeking?
Online Supervision only, I live outside of Dallas
In-person and Online supervision, I live in the Dallas area
In-person supervision only, I live in the DFW area
6
How many sites do you plan to acquire your LPC hours from?
One site only
2 sites
Not sure
7
What populations are you interested in working with and would like supervision on?These are the only populations Heena Khan can provide supervision for.
Young Children/Play Therapy
Adults
Teens/Pre-teens
Families
Geriatrics
Parenting Support
8
What areas are you most interested in practicing?These are the areas that Heena Khan has expertise in.
Trauma
Grief/Loss
Abuse/Intimate Partner Violence
iPerinatal Mental Health/Reproductive Health
Anxiety
Trauma-Informed Yoga
Sand Tray Therapy
Play Therapy
Parenting
Intergenerational Trauma
9
Are you planning to start your own private practice as an Associate?
Yes, as soon as I get my Associate license
No, I plan to work for an organization/private practice.
Not now, but maybe after a few months
10
How are you planning to see clients?
ln-person most of the time, some telehealth
Telehealth most of the time, some in-person
Telehealth only
In-person only
11
Graduating program and university
12
How many classes in your program were online?
13
Where did you complete your practicum? List all sites.
Huge
Large
Normal
Small
Ok
Ok
14
Date of graduation?
Date
Year
Month
Day
15
Have you already taken the NCE exam?
YESNO
16
Have you passed the NCE exam?
Yes
No
I have not received my scores yet
17
Have you received your LPC associate license from the state?
Yes
Not yet, still waiting
I haven't applied yet
18
Are you currently employed?
YESNO
19
Which of the following are you looking for?
Supervision only
Supervision & Employment
20
What kind of employment are you looking for?
Full-time (up to 23 clients)
Not sure yet
Part-time (up to 10 clients)
Flexible
Neither, not looking for employment
21
How did you hear about Heena Khan, LPC-S, RPT-S, CYT?
22
Why Are you interested in supervision with Heena Khan, LPC-S, RPT-S, CYT?
23
Provide three different professional references, one of them must be a previous supervisor/professor. Include, Name, title, location and contact info.
Huge
Large
Normal
Small
Ok
Ok
24
Upload your most current CV below.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
Should be Empty: