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"Off The Record" Group Consultation Application 
Welcome, we are glad you are here. 😎

Thank you for expressing interest in joining "Off The Record", a BIPOC Consultation Group for those who are ready to begin their next steps transitioning into private practice. 

Please complete this application and allow up to one week to set up a consultation with the Facilitator. This allows the facilitator to see what the group is holistically looking for and ways we mutually can move forward as collective if you decided to commit going, "off the record" on a 10 bi-weekly session journey as you make your strides into private practice.

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Section 1: General Bio
Full Name & Pronouns *
Email Address   *
How Did You Hear About Us? *
Section 2: Career Background
Current Role/Title
 *
Current License Held (e.g., LCSW, LMFT, LPC, LMHC, etc) *
Section 3: Transition to Private Practice & Intentions
Why are you interested in transitioning to private practice at this time? (Short answer)
 *
What are your main concerns or challenges regarding the transition? (Short answer)
 *
What are your TOP 3 areas of private practice are you most interested in learning about?
 *
Required
Section 4: Group Suitability, Group Requirements & Keeping it REAL
Are you currently under any supervision? (this group does not count towards your licensing hours)
 *
Are you willing to commit to attending regular group meetings (bi-weekly)? We start in October, break in December and conclude in March.
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Vibe Check: This is an experimental group consultation meaning, we will be actively doing the work in real time and converse around these topics. Does this resonate with you?
Ehh, not my prefrence
Let's Go! I am here for it
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Let's keep it real, is there anything else you would like the facilitator to know about your situation or expectations for the group? (Long answer)
Finances: This consultation group offers a sliding scale based on your relative financial standing. In an effort to reflect disparity in economic condition and access to wealth, the following payment system is designed for those with more wealth to help cover the costs of those with less access to wealth and resources. We trust your discernment of your current financial situation and how you fit into the global economic context.
An Early Bird discount of $100 OFF will be automatically applied to applications received on or prior to Friday, September 6th.
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