Individual Consultation Request
Clinical Supervision As a Licensed Clinical Social Worker in the State of NY (089231), I am pleased to offer consultation and supervision in person in Western New York, or internationally virtually. I provide individual and group supervision sessions for clinicians working towards NYS licensure or for those who are already licensed seeking ongoing clinical support. You might be interested in individual consultation if you are looking for: certification in EMDR or Progressive Counting, or you are looking for clinical guidance, training, or professional support. If you are interested in scheduling a one time, or reoccurring consultation individually, please fill out the following form and Laura will be in contact with you.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
I am interested in:
general individual consultation
PC individual consultation
EMDR individual consultation
Perinatal trauma individual consultation
I will discuss my needs with Laura at a later time.
I understand supervision and consultation opportunities are fee-based. I agree to pay $75 per 60 minute individual meeting. No payment is due until a date is scheduled, however please indicate how you believe you will pay for this service. If I cancel within 12 hours, or no-show the fee is still expected. I understand if the session is canceled by the consultant for any reason, I will be credited a session. I understand I am responsible for keeping record of hours towards certification.
Check (mail to: Laura Ott at 3871 Harlem Road, Suite 206, Cheektowaga NY 14215)
Venmo (@ottcounseling)
Paypal (@ottcounseling)
Zelle (716-783-0699)
Signature
Powered by
Jotform Sign
Clear
Submit
Submit
Should be Empty: