New Supervisee Interest Form
Psychological Behavioral Team Inc
Select all that apply:
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I'm seeking an associate W-2 position.
I'm interested in a clinical volunteer position.
I'm looking for a clinical supervisor.
I have a clinical supervisor.
I am employed by an individual clinician.
I am employed by an individual group.
First name:
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Middle Name:
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Last Name:
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Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Work Email:
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example@example.com
Personal Email:
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example@example.com
License type:
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AMFT
ACSW
ASW
APCC
Psychological Associate
Other
Supervisee license number
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Supervisee license start date:
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-
Month
-
Day
Year
Date
Supervisee license expiration date:
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Month
-
Day
Year
Date
Individual NPI number:
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CAQH number:
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Yes
No
Unsure
Not applicable
CAQH Number or type N/A
Supervisee license linked to California
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Yes
No
Not applicable
Other
Supervisee current place of employment:
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Clinical Service
Current employer name or type NA:
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Current clinical supervisor or type NA:
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Clinical hours remain to complete the board license requirements:
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What is your weekly availability for clinical hours?
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Available to treat:
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In-Person
Telehealth
Both In-Person and Telehealth
Unsure
Areas of interest:
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Able to offer services in a second language?
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Yes
No
Second language or type NA?
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How did you first learn about Psychological Behavioral Health:
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Internet
Indeed or zip recruiter or other similar business.
I was referred by a current clinician affiliated with Psychological Behavioral Health.
I was referred by a clinician NOT affiliated with Psychological Behavioral Health Inc.
Psychological Behavioral Health website
Referred by other associate
Other
Name of Graduate School
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Degree Type
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Example: AMFT; ASW;
Completed Graduate School
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Month
-
Day
Year
Date
Additional Comment
Submit
Should be Empty: