BCBA Supervision Application

BCBA Supervision Application
Please complete the supervision inquiry, and we will reach out within 24 hours to schedule your initial consultation call. If it looks like a good fit, we’ll finalize the contract and set up payment so you can get started as soon as possible.

We are currently licensed in Texas (TX), New Jersey (NJ), and Wisconsin (WI), with Massachusetts (MA) licensing coming soon. We can also supervise in states that do not require BCBA licensure.

Areas that are within our scope of practice: autism, intellectual disability, pscyhiatric conditions, brain injury-- both adults & children. For areas that are outside of this, it may be necessary to go to a Special Interest Group.
Supervisee Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Making Sure You're Ready

Remote supervision isn’t the right fit for everyone. To ensure that our supervisees meet the necessary requirements and can fully benefit from an online supervision format, we ask that you complete the questions below. This will help confirm that you have all the essential components in place to begin supervision successfully.
1. Do you have reliable access to the internet, a microphone, and a phone or computer for video chat meetings?

YesNoI'm working on it.
2. Have you secured a fieldwork site or position where you actively apply behavior-analytic principles?

YesNoI'm working on it.
2a. What is your current ABA-related employer or fieldwork experience site?
Company Name, Location, and Phone Number
2b. What is your position title, and what are your primary job duties in your ABA-related role?
Position Title & Duties
3. Are you able to record at least 15–20 minutes per month of yourself working with a client using ABA strategies? If not, are you open to participating in parent training sessions or other assigned tasks to fulfill this observation requirement? (Note: We offer solutions involving our clients and ABA training opportunities if needed, but it will not substitute for you having an aba-related fieldwork site.)

YesNoI'm working on it.
4. Are you able to obtain parental consent and, if required, organizational approval to record sessions with a client for supervision purposes?*

YesNoI'm working on it.
5. Have you started at least the first course in a BACB-approved ABA course sequence?*

YesNo
6. Are you able to meet regularly in accordance with BACB supervision requirements?

YesNo
7. Are you aware of the supervision costs? We offer two options to fit your needs:$375/month for the Concentrated Track$200/month for Regular Fieldwork Supervision. If you’re starting mid-month, we offer pro-rated pricing at $30 per supervision hour.Payments are made in advance through Square to keep things simple and hassle-free!

YesNo
Education & ABA Experience

Giving us an idea of your skills & experience will let us know the flexibility we will have in unrestricted tasks.
8. University Attending/Attended for BCBA / BCaBA coursework*
9. My BACB coursework sequence is:

In ProgressCompletedNot started
10. How many fieldwork experience hours have you completed so far, and how many do you still need to fulfill BACB requirements?
Total Hours completed - # of Restricted vs # of Unrestricted Completed
11. What client populations have you worked with in the past?
ex: Autism, Brain Injury, Intellectual Disability, Adults, Children, ECI
12. What supervision package are seeking?

Concentrated Fieldwork Experience $375/monthReg. Fieldwork Experience $200/month
13. How soon would you like to start online supervision?

As soon as possibleWithin 1-3 monthsWithin 6 months
14. What is the primary reason that you are seeking supervision services out side of your current position?
15. Please give us some dates & times in the next week that we can schedule a call to discuss your needs and goals in getting supervision started.
Scheduling Supervision Times

Please share your availability. Mark all that apply so that we can see our ability to meet your needs.

Weekday Availability for Supervision

	Mon	Tues	Wed	Thurs	Fri
12-1:00 PM
6-7:00pm
7-8:00pm
8-8:30pm

Weekday Availability for Supervision

	Sat
6-7:00am
7-8:00am
8-9:00am
9-10:00am
10-10:30am

15. Note any other considerations or concerns that should be discussed.
Should be Empty:

BCBA Supervision Application

Making Sure You're Ready

Education & ABA Experience

Scheduling Supervision Times