Supervision Referral

Your Environment for Supervision
For supervision sessions, can you arrange to be in a private space with your device, with adequate internet connection for video calls, where you won't be interrupted or overheard during sessions?

YesNo
Online supervision is not appropriate unless it's attended in a private space with adequate internet connection. You might consider sourcing a local supervisor who works in person.

Contact Details

These details are required in order to contact you regarding appointments, and to get you help in the event of an emergency.
Name*

First Name(s)Last Name(s)
Preferred Name*
What would you like me to call you?
Gender*
Please specify your gender and preferred pronouns
Date of Birth*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

City/Town/VillageCounty/State

Postal / Zip Code
General Practitioner (GP) Name
GP Practice Phone Number*
GP Practice Address*

Street Address

General Practitioner (GP) Name

City/Town/VillageCounty/State

Postal/Zip CodeCountry
Emergency Contact*

Emergency Contact Name

Street Address Line 2

Relationship to You Relationship to You

Emergency Contact Phone Number
Emergency Contact Phone Number*

If there is anything else you'd like to mention about you or your therapy practice, please do so here:
Should be Empty:

Clinical Supervision Referral Form