Supervision Inquiry Form
Contact Information
Please provide information that it is safe to contact you at.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
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Basic Information
Which state are you currently located in or planning to be located in?
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Florida
Idaho
What supervision format(s) are you interested in?
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Individual
Triadic
Group
Which license type(s) are you targeting to get?
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Mental Health Counselor (LMHC, LCPC, or LPC)
Marriage & Family Therapist (LMFT)
Social Worker (LCSW)
Multiple licenses (LMHC, LCPC, LPC, LMFT, and/or LCSW)
When did you graduate or are expected to graduate?
*
Include month and year.
Are you already receiving supervision?
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No, I am not already receiving supervision.
Yes, but I am looking to switch supervisors.
Yes, but I am wanting to add an additional supervisor.
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Goodness of Fit
The next few sections will help me determine whether we would be a good fit in working together based on my style and your needs. It also helps expedite whether having a phone consultation would be productive. Please answer as fully as you can.
(1) Please provide some information on your therapy modalities that you currently using or wanting to use more? (2) Where are you planning to work or are currently working? (3) Also, include some information on the populations you work with.
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Please describe some supervision wants you have, as well as things you don't want, that are deal breakers for you.
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Please list the dates and times you would be available for a free phone consultation.
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