SOUND Life Recovery - Individual Supervision

Individual Supervision - Application

Prerequisites: 1) WA State associate level licensed professional, 2) professional liability insurance - minimum 1mil/3mil with Jeffery J. Roskelley, LICSW & SOUND Life Recovery, PLLC added as additional insured, 3) primary supervisor in place IF SLR supervisor is acting as a secondary supervisor (not necessary if SLR is acting as primary)
Welcome WA State Associates!

Supervision is a big investment of both your time and your money. It's also a big responsibility for a supervisor. For these reasons, we've formalized an application and contracting process to maximize the potential of being a "right match".

Please share any information we may find useful as we consider if we're a good fit for your supervision needs and how we might best support you. You can keep these responses fairly brief, if you'd like, however we request that they include enough information to offer a balanced view of your interests, work, and supervisory experiences. We'll follow up with questions, as needed.

If you're aware we have no current seats in our 1:1 supervision program and you prefer to bypass the application until you know there is an open seat, you may add your name to our waitlist. That waitlist can be found in our professional FAQ at soundliferecovery.com, or by clicking here.

We appreciate your interest in further developing your clinical skills and look forward to being in touch after we review your application. Please feel free to contact us at: info@soundliferecovery.com if you have any questions.
Saving Your Work for Multiple Sessions:

If you would like to fill out this form in multiple sessions:

1. Expand the last section, titled "Save or Submit".

2. Tap "Save" after each session.

3. A pop up will appear. To sign in without creating an account, tap the link of very small print at the bottom of the pop up that says “Skip Create an Account”.

4. Another pop up will appear. Enter your email AND save your individualized access link in a safe place, such as your desktop, bookmarks, or favorites folder. Doing both offers you double insurance that you won't lose access to your work.

5. You should receive an email from Jotform with a link to access your partially completed application.

*You must save this form after each session or your work will be lost. The save button can be located in the last section.*

Your Information
Name, as it appears on professional license*

First NameLast Name
Preferred name
If different from name on license
Cell Phone Number*

Area CodePhone Number
Your Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Information About Your License, Hours, & Liability Insurance
What associates license do you hold?*

LMHCALSWALMFTASUDPOther
What is your professional license number?*
When does your current license expire?*

MonthDayYear
Date
License Verification: Please upload a copy of your current license here. Alternately, you can look up your credential on the WA State DOH Provider Credential Search (found here), take a screenshot of the screen confirming your professional license is active and in good standing, and upload that image.
Upload your license verification file here:*

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License verification Cancelof
How many hours do you have previously accumulated that are eligible toward meeting your licensure requirements? *
How many hours do you still need to accumulate?*
How many hours do you hope to acquire with SOUND Life Recovery?*
Upload a copy of your professional liability insurance here, if you have an existing individual policy at the levels required for our program. If you don't yet have a policy, this can be uploaded into our practice management system prior to your first supervision session.

Browse Files

Cancelof
Planning to finish this form later? Don't forget to save!

Information About Your Professional Interests
Briefly describe your current work activity.*
Is your current work reflective of the work you ultimately hope to be doing? Please explain.*
Please briefly share any professional development goals you may have, if not already addressed in the previous question.*
Planning to finish this form later? Don't forget to save!

Past Training, Experience, & Self Reflection
Please share information about past experience related to substance use, SMI, CBT, CBTp, and/or ACT.*
Please describe areas you feel are professional strengths.*
Please describe areas you recognize as needing improvement or simply have a desire to improve to increase professional competency. *
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Approved Supervisors - Current
The following reference sections serve two purposes. They 1) offer us contact information of any other supervisors who applicants may be working with, and 2) allows us to clarify supervisory role delineation.

The questions below refer to WA State approved superivsors for the purposes of accumulation of hours toward professional licensure, not a general work supervisor.

By the time you finish both Approved Supervisor sections, we should have names and contact information for all of your current and past WA State approved supervisors.

At SLR, for our purposes, this is how we define primary vs secondary supervision:

Primary supervision: Supervision with a main supervisor ("primary supervisor") who has primary responsibility for the supervision of the associate licensee. Therapy clients are seen under the license and primary supervision of this clinical supervisor. Primary supervisors have final say on all therapy recommendations. Primary supervision may support caseload and treatment plan review, theory and practice, relevant WA State rules & laws, standards of practice, coordination of work with other professionals and parties, relevant professional literature and research, and other therapy related issues. The primary supervisor has final authority if there is not agreement between supervisors in a therapeutic recommendation.

Secondary supervision: Supervision for licensure candidates who already have a primary supervisor in place. Secondary supervision may provide secondary guidance all areas addressed by a primary supervisor. One of the main purposes for choosing secondary supervision with SOUND Life Recovery is to deepen understanding of general CBT, ACT, CBT for Psychosis (CBTp), and an integrated approach to the treatment of co-occurring disorders to further enhance the supervisory experience they receive with their primary supervisor. When acting as a secondary supervisor, SOUND Life Recovery welcomes communication & collaboration to include the primary supervisor at any point for the benefit of the supervisee and their clients.
Are you seeking primary or secondary supervision with SOUND Life Recovery?*

PrimarySecondaryOther
Approved Supervisor Information - Primary

If you have a primary supervisor who will be seeing you during the same period of time as the SOUND Life Recovery supervisor would, should you work with us, please share the primary supervisor's information here.
Full name of PRIMARY supervisor, IF you have one.

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Please share the setting of this supervision.
About how long have you been working with this supervisor? A general timeline or number of supervision hours accumulated is fine.
Is there anything you'd like us to know about this supervisory experience before we call as a reference?
Approved Supervisor Information - Other Current

Do you expect to be receiving primary or secondary supervision from any other supervisors not listed above during your time with us? This only pertains to those supervisors you plan to see concurrently for accumulation of supervision hours toward licensure. If so, please share contact information for any other supervisors below. If you have more supervisors to share, there will be an open text box at the end of this document for sharing of further information.
Name of supervisor

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Do you consider this supervisor primary or secondary?

PrimarySecondary
Please share the setting of this supervision.
About how long have you been working with this supervisor? A general timeline or number of supervision hours accumulated is fine.
Is there anything you'd like us to know about this supervisory experience before we call as a reference?
Planning to finish this form later? Don't forget to save!

Approved Supervisors - Past
Please provide the names, email, and phone number for all past, inactive clinical supervisors specific to your accumulation of your post graduate hours toward licensure.

By the time you finish both Approved Supervisor sections, we should have names and contact information for all of your current and past WA State approved supervisors.
Name of supervisor

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Please share the setting of this supervision.
About how long did you work with this supervisor? A general timeline or number of supervision hours accumulated is fine.
Is there anything you'd like us to know about this supervisory experience before we call as a reference?
Name of supervisor

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Please share the setting of this supervision.
About how long did you work with this supervisor? A general timeline or number of supervision hours accumulated is fine.
Is there anything you'd like us to know about this supervisory experience before we call as a reference?
Planning to finish this form later? Don't forget to save!

Professional References

We utilize past supervisors as professional references. In total we would like at least 3 final references who are familiar with you in a professional setting. If you have 3 already from the Approved Supervisor information (above), you can skip this section. You are welcome to share more than 3 references total for us to call.

Number of Approved Supervisors shared above	Number of References to share in this section
0	3
1	2
2	1
3	0

Reference 1
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
What is/was the nature of your relationship with this reference?
About how long was your professional relationship with this reference?
Is there anything you'd like us to know about this relationship before we contact this person?
Reference 2
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
What is/was the nature of your relationship with this reference?
About how long was your professional relationship with this reference?
Is there anything you'd like us to know about this relationship before we contact this person?
Reference 3
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
What is/was the nature of your relationship with this reference?
About how long was your professional relationship with this reference?
Is there anything you'd like us to know about this relationship before we contact this person?
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Past Disciplinary Action
Have you ever had any complaint, report, warning, or disciplinary action taken against you from any disciplinary body including but not limited to state licensing boards, national certification organizations, and agency workplaces. Please explain who, what, why, and how it was resolved.
YesNo
If yes, please explain who, what, why, and how it was resolved.
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Miscellaneous
What led you to reach out for supervision specifically with us?
Is there anything else you'd like to share?
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Agreement & Signature
Please use your mouse or trackpad to write your signature below.
By providing your e-signature below, and submitting this form, you: 1) are applying for approved supervision with SOUND Life Recovery, 2) confirm that all information provided is true and correct to the best of your knowledge, 3) authorize SOUND Life Recovery to contact you and any references listed above, and 4) agree to communicate via electronic means.

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Individual Supervision - Application

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