Clinical Supervision Inquiry Form

Clinical Supervision Inquiry Form

Ed Geraty LCSW-C, LICSW, LCSW
Basic information:

. I am a licensed licensed clinical social worker in WV, NY, VA, MD, FL, VT, DE and DC. Once you complete the following information and submit this form, I will contact you via text 410-804-1934 or email from EdGeratyLCSW-C@proton.me to discuss next steps.
Date of today

MonthDayYear
Date
Email
example@example.com
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number where you can recieve text messages
Please enter a valid phone number.
State where you reside
Name of graduate school completed
License Credential
Graduate license number
Date you became licensed
Please be aware that individual suervision sessions are billed at 90$ per session and that cancelations with less than 24 hr notice or a no show is billed to you at 75$ for the session.

All supervision sessions are provided through a HIPAA compliant teletherapy platform.
Once you complete the above information and submit this form, I will contact you via text 410-804-1934 or email from EdGeratyLCSW-C@proton.me to discuss next steps.
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