Clinical Supervision Inquiry
Questionnaire Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Place of Employment
*
Position / Title
*
Graduate School Attended
*
Year Graduated
*
Current Licensure Level
*
Please Select
LSW
LMSW
LGSW
I do not hold any social work license
Name and Address of Regulatory Board ( for the current state that you are in & in which you are seeking licensure)?
*
Number of Hours Needed to Complete Supervision
*
Have You Completed Any Hours Towards completion, prior to contacting Empowering Minds Counseling & Consultant Services, LLC?
Yes
No
If, Yes How Many?
Type of Supervision Requesting?
*
Individual-$75
Group-$60
Per your state, what is the frequency of supervision sessions necessary to meet board requirements?
*
Which Client Population Do You Enjoy Working With ( CHECK ALL THAT APPLY)
*
Children
Adults
Teenagers
Other
Describe your knowledge and skills that have been acquired from previous professional training and experience such as: diagnostic assessment and treatment; ethical standards of practice; state and federal laws and rules; record keeping; cultural competence, e.g., knowledge and experience with cultural norms of behavior for clients served by you (e.g., ethnicity, race, age, class, gender, sexual orientation, religion, immigration status, literacy, and mental or physical disability); commitment to maintaining cultural competence as an ongoing process; methods for establishing treatment relationship with clients and patients; methods for including family members in clients’ treatment when appropriate; communication with other professionals in developing diagnosis and treatment plans and assuring continuity of care?
*
Describe you professional strengths either you, teachers and former supervisors have identified:
*
Professional weaknesses or concerns practice that either you, teachers and former supervisors have identified:
*
Describe your greatest sources of professional concerns or anxiety:
*
Describe how you learn best & your specific learning style
*
Describe any learning barriers and accomodations, if any are needed.
*
If you were a board game, which game would you be, why would you be that game and what social issue would you address by being that game?
*
How did you hear about us?
*
Referral
Facebook
Online Add
Website
Instagram
Other
Attachment
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Upload a copy of current resume, licensure, copy of your state licensing board supervision packet and any relevant training experience.
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