Practice & Supervision Support Application

1

Full Name* This field is required.

First Name

Last Name

2

Email Address* This field is required.

example@example.com

3

License type and state of licensure* This field is required.

4

Which best describes the kind of support you’re seeking?* This field is required.

Starting a private practice

Adding supervision to an existing practice

Strengthening the structure of an existing practice

More than one of the above

Not sure yet

5

Tell me about your current situation, what’s prompting you to reach out, and what you specifically want help with.* This field is required.(Examples: business/practice structure, policies, paperwork, etc.)

6

What have you already completed?* This field is required.

Practice setup steps

Supervisor training/certification

Practice paperwork or policies

EHR / documentation systems

Insurance credentialing

None of the above

Other

7

What timeline are you working with?* This field is required.

30 days

60 -90 days

3-6 months

8

Are you prepared to invest $497 for this support if accepted?* This field is required.

Yes

Not yet

I have questions first

9

Anything else I should know before reviewing your application?