• Clinical Supervisor Interest Form

    Please complete form to set up an interview.

  • About you

  • Professional Information

  • What is your license type?*
  • Are you licensed to practice and supervise in California?*
  • What is the original issue date of the license?*
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  • License expiration date*
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  • Do you have malpractice insurance?*
  • Current work status (Select all applicable)*
  • Do offer clinical services in a second language?*
  • I am credentialed with the following PBH insurance carriers (Exclude Headway and others)?*

  • Clinical Information

  • Which areas can you supervise?*
  • Which areas do you prefer NOT to supervise?*

  • Supervision Information

  • Are you currently an independent contractor with Psychological Behavioral Health?*
  • What type of supervision do you wish to offer?*
  • Are you available to supervise via telehealth or in-person or both? *
  • Do you lease a private office?*
  • Do you plan to supervise at your office?*
  • Which associates are you eligible to supervise?*
  • Are you currently supervising associates with any group or entity or as part of your group?*
  • Have you met required state and professional supervision requirements for clinical supervision?*

  • Compensation

  • Are you interested in employment as a clinical supervisor?*
  • Date*
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  • Should be Empty: