Clinical Supervision Inquiry Form

Clinical Supervision Inquiry Form
Heading
Name

First NameLast Name
Full Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
What type of supervision are you seeking?*

NEW LPC Associate SupervisionTransitioning LPC Associate SupervisionNone; Seeking contract employment opportunities only
What is/are your theoretical orientation(s) you have a passion for and why?*
What is your Counselor Identity?*
Did you attend a CACREP University?*

YESNO
Have you or when will you complete your NCE Exam? If not, what date do you expect to sit for your exam?*
Do you have a clinical site in mind (Please specify if applicable)?*
Are you interested in joining Counseling Connections of San Antonio/Franklin Training & Consulting, Inc (Group Practice) [Optional for LPC Associates]?*

YESNOMAYBEOTHER
When are you seeking to apply for licensure?*
References (Please list three references with name, email address, and phone):*
NOTE: DO NOT USE FRIENDS OR FAMILY.
How did you learn about me?*
Best day/time to be contacted?

MonthDayYearHourMinutesAM/PM Option
Upload Resume*

Upload a File

Cancelof
Note: This is NOT for employment. This inquiry screen is ONLY to request LPC Supervision for the purposes of state licensure in Texas.

If you have NOT received contact within THREE business days from submission, please CALL and leave a voiemail at 210-446-8255.
Additional Resources:

Supervisor(s):

https://www.psychologytoday.com/us/therapists/supervision-services

Military Spouses (Supervision Reimbursement):

https://www.militaryfamily.org/licensing-certification/

Veterans (Licensing Exam Reimbursement):

https://www.vba.va.gov/pubs/forms/VBA-22-0803-ARE.pdf
Should be Empty:

Clinical Supervision Inquiry Form

Heading