Clinical Supervisor Interest Form
Please complete form to set up an interview.
About you
First name
*
Middle Name or type NA
*
Last Name
*
What is your current office business address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
ejemplo@ejemplo.com
Business phone number
*
Personal phone number
*
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Professional Information
What is your license type?
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LMFT
LCSW
LPCC
Psychologist
Nurse Practitioner
Psychiatrist
Other
Are you licensed to practice and supervise in California?
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Yes
No
Not applicable
Do you have another license type not listed above?
*
What is your professional license number?
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What is the original issue date of the license?
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-
Month
-
Day
Year
Date
License expiration date
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-
Month
-
Day
Year
Date
Individual NPI number?
*
CAQH number?
*
Do you have malpractice insurance?
*
Yes
No
Are you working or affiliated with any other group or entity not listed above? If yes, add the name or type NA.
*
Current work status (Select all applicable)
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My work is 100% affiliated with Psychological
Full time private practice
Part-time private practice
Behavioral Health Inc
I am affiliated with Rula
I am affiliated with Alma
I am affiliated with Grow Therapy
I am affiliated with Octave
I am affiliated with BetterHelp
I am affiliated with Headway (PBH)
I am affiliated with Headway (Individual)
Other
Do offer clinical services in a second language?
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Yes
No
Maybe
Other
Second language or type NA?
*
I am credentialed with the following PBH insurance carriers (Exclude Headway and others)?
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Aetna
Anthem Blue Cross California
Blue Shield of California
CalOptima
Cigna/Evernorth
Health Net (MHN is now part of Health Net)
Kaiser Permanente - Southern
Gold Coast Health (Carelon)
LA Care (Carelon)
Medicare
Optum/Untied Healthcare
Other
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Clinical Information
Which areas can you supervise?
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ADHD
Aggression
Anger
Adoption
Agoraphobia
Anxiety
Attention-deficit/hyperactivity disorder
Autism Spectrum Disorder
Bariatric Surgery
Bipolar
Bulimia Nervosa
Christian Counseling
Cultural related concerns
Depression
Divorce/Blended Family Issues
Domestic Violence
Eating Disorder
End of Life Issues
Family related issues
Gay/Lesbian Issues
Generalized Anxiety Disorder
Grief/Loss
HIV/AIDS Related Issues
Identity Related Concerns
Infertility
Learning related disroders
Marital Concerns
Men Issues
Medication Services
Obsessive-Compulsive Disorder
Oppositional Defiant Disorder
Pain related concerns
Panic Disorder
Pesonality Disorders
Phobias
Postpartum Disorders
Psychotic Disorders
PTSD/Trauma
Prenatal issues
Schizophrenia
Sexual Abuse
Sexual Disorders
Substance Use Disrorder
Transgender concerns
Women Issues
Other
Which areas do you prefer NOT to supervise?
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ADHD
Aggression
Anger
Adoption
Agoraphobia
Anxiety
Attention-deficit/hyperactivity disorder
Autism Spectrum Disorder
Bariatric Surgery
Bipolar
Bulimia Nervosa
Christian Counseling
Cultural related concerns
Depression
Divorce/Blended Family Issues
Domestic Violence
Eating Disorder
End of Life Issues
Family related issues
Gay/Lesbian Issues
Generalized Anxiety Disorder
Grief/Loss
HIV/AIDS Related Issues
Identity Related Concerns
Infertility
Learning related disroders
Marital Concerns
Men Issues
Medication Services
Obsessive-Compulsive Disorder
Oppositional Defiant Disorder
Pain related concerns
Panic Disorder
Pesonality Disorders
Phobias
Postpartum Disorders
Psychotic Disorders
PTSD/Trauma
Prenatal issues
Schizophrenia
Sexual Abuse
Sexual Disorders
Substance Use Disrorder
Transgender concerns
Women Issues
Other
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Supervision Information
Are you currently an independent contractor with Psychological Behavioral Health?
*
Yes
No
Other
What type of supervision do you wish to offer?
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Individual Supervision only
Group Supervision only
Individual and group supervision
Unsure
Other
Are you available to supervise via telehealth or in-person or both?
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Telehealth - I am available to supervise.
In-person - I am available to supervise.
Telehealth and/or in-person - I am available to supervise.
Other
Do you lease a private office?
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Yes
No
Not applicable
Other
Do you plan to supervise at your office?
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Yes
No
Unsure
I can only offer telehealth supervision.
I would like to use PBT office space.
I need help finding office space.
Not applicable
Which associates are you eligible to supervise?
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ASW
ACSW
APCC
Psychological Assistant
Other
Are you currently supervising associates with any group or entity or as part of your group?
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Yes
No
Other
If you are currently supervising with another group, please provide the name of the group or entity or type NA.
*
How many associates have you supervised or type NA?
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If you have supervised associates, what year did you first supervise an associate or type NA?
*
If you have supervised associates, what year was last time you supervised an associate or type NA?
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How many associates do you wish to supervise at one time?
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How many hours do you have available per week for supervision work?
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What days and times are you available to offer supervision?
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Have you met required state and professional supervision requirements for clinical supervision?
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Yes
No
Other
Date you are available to start:
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Compensation
Are you interested in employment as a clinical supervisor?
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Yes - Employee (W-2)
Unsure
Other
What is your preferred hourly compensation?
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In addition to hourly pay, do you request any other form of compensation for the supervisory role?
*
Additional Comment
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Date
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
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