Clinical Group Preference

UNIVERSITY SUPERVISION GROUP PREFERENCE
Name*

First NameLast Name
Student E-mail*
example@example.com
Indicate your reason for completing this form*

Starting my clinical experience (have never been assigned to a group before)Starting my internship courses (have completed Practicum courses)My group time no longer works for me (NOT at the start of practicum or internship)
Reason for requesting a new group:*
Current Course or Most Recently Completed Course
Current Faculty
CURRENT FACULTY Email
example@example.com
Current Local Clinical Supervisor Name:*
Current local clinical supervisor Email:*
example@example.com
MY current local clinical supervisor is

AAMFT- ApprovedAAMFT-Approved CandidateState ApprovedI do not know
Do You Have More Than One Local Supervisor?

Yes - one more local supervisorYes - two more local supervisorsNo
2nd Current Local Clinical Supervisor Name:
2nd Current local clinical supervisor Email:
example@example.com
MY 2nd current local clinical supervisor is

AAMFT- ApprovedAAMFT-Approved CandidateState ApprovedI do not know
3rd Current Local Clinical Supervisor Name:
3rd Current local clinical supervisor Email:
example@example.com
MY 3rd current local clinical supervisor is

AAMFT- ApprovedAAMFT-Approved CandidateState ApprovedI do not know
Current Site(s):*
Projected Course End Date of Practicum II:

MonthDayYear
Date
Will you Request an extension?

YESNO
Please indicate your Preferred time zone:*

Indicate your day and time options for attendance in the weekly, 2.5-hour university supervision groups. These are mandatory groups that you will be required to attend starting the first week of your first clinical course for at least a full year. Please note that spots cannot be reserved, and the groups change weekly. The team will do their best to provide you with your preferred options, but this may not always be possible. You will need to put a response for EVERY time option indicated in the table.*

	Preferred	Possible	Unavailable
M 9 am Eastern (ET), 8 am Central (CT), 7 am Mountain (MT), 6 am Pacific (PT)
M 12:30 pm ET, 11:30 am CT, 10:30 am MT, 9:30 am PT
M 2 pm ET, 1 pm CT, 12 pm MT, 11 am PT
M 3 pm EST, 2 pm CT, 1 pm MT, 12 pm PT
M 6 pm ET, 5 pm CT, 4 pm MT, 3 pm PT
M 7 pm ET, 6 pm CT, 5 pm MT, 4 pm PT
M 8 pm ET, 7 pm CT, 6 pm MT, 5 pm PT
T 9 am ET, 8 am CT, 7 am MT, 6 am PT
T 10:30 am ET, 9:30 am CT, 8:30 am MT, 7:30 am PT
T 12 pm ET, 11 am CT, 10 am MT, 9 am PT
T 4:30 pm ET, 3:30 pm CT, 2:30 pm MT, 1:30 pm PT
T 6 pm ET, 5 pm CT, 4 pm MT, 3 pm PT
T 7 pm ET, 6 pm CT, 5 pm MT, 4 pm PT
T 8:30 pm ET, 7:30 pm CT, 6:30 pm MT, 5:30 pm PT
W 9 am ET, 8 am CT, 7 am MT, 6 am PT
W 1 pm ET, 12 pm CT, 11 am MT, 10 am PT
W 2:30 pm ET, 1:30 pm CT, 12:30 pm MT, 11:30 am PT
W 3:30 pm ET, 2:30pm CT, 1:30 pm MT, 12:30 pm PT
W 6:30 pm ET, 5:30pm CT, 4:30 pm MT, 3:30 pm PT
W 8 pm ET, 7 pm CT, 6 pm MT, 5 pm PT
Th 8 am ET, 7 am CT, 6 am MT, 5 am PT
Th 9 am ET, 8 am CT, 7 am MT, 6 am PT
Th 11 am ET, 10 am CT, 9 am MT, 8 am PT
Th 6 pm ET, 5 pm CT, 4 pm MT, 3 pm PT
Th 6:30 pm ET, 5:30 pm CT, 4:30 pm MT, 3:30 pm PT
Th 9 pm ET, 8 pm CT, 7 pm MT, 6 pm PT
F 9 am ET, 8 am CT, 7 am MT, 6 am PT
F 10:30 am ET, 9:30 am CT, 8:30 am MT, 7:30 am PT
F 1 pm ET, 12 pm CT, 11 am MT, 10 am PT
F 2 pm ET, 1 pm CT, 12 pm MT, 11 am PT

Indicate your First Group Choice:
Indicate your Second Group Choice:
Do NOT select the same time for every option
Indicate your Third Group Choice:
Do NOT select the same time for every option
Indicate your Fourth Group Choice:
Do NOT select the same time for every option
Indicate your Fifth Group Choice:
Do NOT select the same time for every option
SElect ALL group OPTIONS THAT WILL WORK for your schedule (minimum 5 options)

M 9 am Eastern (ET), 8 am Central (CT), 7 am Mountain (MT), 6 am Pacific (PT)M 1 pm ET, 12 pm CT, 11 am MT, 10 am PTM 2 pm ET, 1 pm CT, 12 pm MT, 11 am PTM 3 pm EST, 2 pm CT, 11 am MT, 10 am PTM 6:30 pm ET, 5:30 pm CT, 4:30 pm MT, 3:30 pm PTM 7 pm ET, 6 pm CT, 5 pm MT, 4 pm PTM 8:30 pm ET, 7:30 pm CT, 6:30 pm MT, 5:30 pm PTT 9 am ET, 8 am CT, 7 am MT, 6 am PTT 11 am ET, 10 am CT, 9 am MT, 8 am PTT 5 pm ET, 4 pm CT, 3 pm MT, 2 pm PTT 6 pm ET, 5 pm CT, 4 pm MT, 3 pm PTT 7 pm ET, 6 pm CT, 5 pm MT, 4 pm PTT 9 pm ET, 8 pm CT, 7 pm MT, 6 pm PTW 9 am ET, 8 am CT, 7 am MT, 6 am PTW 1 pm ET, 12 pm CT, 11 am MT, 10 am PTW 3 pm ET, 2 pm CT, 1 pm MT, 12 pm PTW 4 pm ET, 3 pm CT, 2 pm MT, 1 pm PTW 7 pm ET, 6 pm CT, 5 pm MT, 4 pm PTW 8:30 pm ET, 7:30 pm CT, 6:30 pm MT, 5:30 pm PTW 9:30 pm ET, 8:30 pm CT, 7:30 pm MT, 6:30 pm PTR 9 am ET, 8 am CT, 7 am MT, 6 am PTR 11 am ET, 10 am CT, 9 am MT, 8 am PTR 6:30 pm ET, 5:30 pm CT, 4:30 pm MT, 3:30 pm PTR 7 pm ET, 6 pm CT, 5 pm MT, 4 pm PTR 9:30 pm ET, 8:30 pm CT, 7:30 pm MT, 6:30 pm PTF 9 am ET, 8 am CT, 7 am MT, 6 am PTF 11 am ET, 10 am CT, 9 am MT, 8 am PTF 1 pm ET, 12 pm CT, 11 am MT, 10 am PT
Please indicate any information you would like the clinical coordinator to be aware of:
We will be in contact with your group information as soon as possible.

Please note that we will do our best to place you with your top choices, the more options you provide us with the better chances we'll place you in a group that works with your schedule.

Send any questions to MFTtraining@nu.edu
ADMIN USE ONLY

Students should not complete ANYTHING below this part of the form.
New University Group Day
New University Group Time
New University Group Faculty Name
New University Group Faculty Email
Start Date for New Group

MonthDayYear
Date
Additional Comments:
Should be Empty:

UNIVERSITY SUPERVISION GROUP PREFERENCE

ADMIN USE ONLY