Clinical Supervisor Interest Form

First name*

Middle Name or type NA*

Last Name*

Email

ejemplo@ejemplo.com

Número de teléfono

Favor ingrese un número de teléfono válido.

Work Status (Select all applicable)*

Are you working or affiliated with any other group or entity not listed above? If no, type NA.*

What is your current office business address (State, City, and Zip code)?*

Business phone number*

Personal phone number*

Are you licensed to practice and supervise in California?*

YesNoNot applicable

What is your license type?*

What is your professional license number?*

What is the original issue date of the license?*

Date

License expiration date*

Date

Individual NPI number?*

CAQH number?*

Do you have another license type not listed above?*

Do offer clinical services in a second language?*

YesNoMaybeOther

Second language or type NA?*

Do you have malpractice insurance?*

YesNo

I am credentialed with the following PBH insurance carriers through PBH (Exclude Headway credentialing)?*

Are you available to supervise via telehealth or in-person or both? *

Telehealth - I am available to supervise.In-person - I am available to supervise.Telehealth and/or in-person - I am available to supervise.Other

What days and times are you available to offer supervision?*

Date you are available to start:

Which areas can you supervise?*

Which areas do you prefer NOT to supervise?*

Do you plan to supervise at your office?*

Do you lease a private office?*

YesNoNot applicableOther

What is your preferred hourly compensation?*

In addition to hourly pay, do you request any other form of compensation for the supervisory role?*

Additional Comment

Date

Hour MinutesAM/PM Option

About you