PGP Supervision Form

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Area Code
Phone Number
4
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
What certification are you pursuing?* This field is required.
Board Certified Behavior Analyst (BCBA)
Board Certified Assistance Behavior Analyst (BCaBA)
6
Have you started your BACB approved coursework?* This field is required.
Yes, Started
Yes, Completed
Not yet
7
University* This field is required.
8
Date StartedIf Applicable
Date
Year
Month
Day
9
Current ABA or Special Education Employment TypeAt a School for kids with EDB or ESE issues, ABA Clinic, home, not yet working in field, etc
0/150
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Large
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Small
Ok
Ok
10
Interests in the Field:
0/150
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Small
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Ok
11
Do you have any ABA research experience?* This field is required.
Yes
No
I'm not sure
12
Have you completed any experience hours with another supervisor?* This field is required.
Yes
No
I'm not sure
13
Will you be earning hours through your current place of employment or seeking to work with Full Spectrum?* This field is required.If you reside in a state we are serving you must work with FSBA – FL, MI, NC, OR
Yes
No
Maybe
14
How many hours do you plan on accruing towards supervision per week?* This field is required.Please note, if you only receive 10 hours per week, you will still be supervised no less than 1.5 hrs per period. You can only accrue 30 hours per week maximum, and that can include both direct and indirect hour
10 Hours
10-20 Hours
20-30 Hours
15
If you will be working for Full Spectrum ABA, you will be paid during your supervision period. How many hours would you like to bill/work with clients per week?* This field is required.
10 Hours
10-20 Hours
20-30 Hours
30-40 Hours
40+ Hours
16
What days/times are you available for live supervision or virtual group supervision?* This field is required.Via Phone or Video Chat. Select all that apply.
Monday 8 AM to 12 PM
Monday 4 PM to 8 PM
Tuesday 8 AM to 12 PM
Tuesday 12 PM to 4 PM
Tuesday 4 PM to 8 PM
Wednesday 8 AM to 12 PM
Wednesday 12 PM to 4 PM
Wednesday 4 PM to 8 PM
Thursday 8 AM to 12 PM
Thursday 12 PM to 4 PM
Thursday 4 PM to 8 PM
Friday 8 AM to 12 PM
Friday 12 PM to 4 PM
Friday 4 PM to 8 PM
Saturday 8 AM to 12 PM
Saturday 12 PM to 4 PM
Saturday 4 PM to 8 PM
17
Any other details about your availability?
18
If accepted, when would you be interested in starting supervision?
Date
Year
Month
Day
19
How did you hear about Full Spectrum's supervision program?
Co-Worker
Social Media
Google
Friend
20
Briefly describe you past experience working in the field of ABA.* This field is required.If you have no experience in this field, describe your current employment setting.
0/200
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Ok
21
Why are you interested in receiving your supervision through Full Spectrum ABA?
22
Why are you interested in pursuing your BCBA/BCaBA certification and what are your long term goals?
23
Is there anything else you'd like to share about yourself or your career?
24
Upload Resume or CV
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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25
How excited are you to begin your PGP Supervision Program?Slide left or right.
26
Date* This field is required.Date of form submission.
Date
Year
Month
Day
27
Signature* This field is required.Please use your mouse or finger to electronically sign your application.
28
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