BCBA/BCaBA Supervision Application

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First Name *

Last Name *

Email *

Gmail Account *

To be used for video chats

Phone Number *

City, State *

Time Zone *

What certification are you pursuing? *

Board Certified Behavior Analyst (BCBA)

Board Certified Assistance Behavior Analyst (BCaBA)

Have you started your BACB approved coursework? *

Yes, started

Yes, completed

Not yet started

University *

Date started (if applicable)

YYYY

Have you completed any of your supervision hours under the 4th edition task list (prior to 2022)? *

Yes

I'm not sure

Employment Type *

School, ABA Clinic, SLP-Assistant, etc.

Have you completed any experience hours with another supervisor? *

Yes

I'm not sure

If yes, how many hours have you completed?

Will you be earning hours through your place of employment? *

Yes

Maybe

How many hours do you plan on earning per week? *

Please note, if you only receive 10 hours per week, you will still be supervised no less than 1.5 hrs per period.

10 hours

10-20 hours

20-30 hours (or more)

What days/times are you available for live supervision (via phone or video chat)

Sunday *

Morning (8-11am)

Afternoon (11-2pm)

Late Afternoon (2-6pm)

Evening (6-10pm)

Not Available

Required

Monday *

Morning (8-11am)

Afternoon (11-2pm)

Late Afternoon (2-6pm)

Evening (6-10pm)

Not Available

Required

Tuesday *

Morning (8-11am)

Afternoon (11-2pm)

Late Afternoon (2-6pm)

Evening (6-10pm)

Not Available

Required

Wednesday *

Morning (8-11am)

Afternoon (11-2pm)

Late Afternoon (2-6pm)

Evening (6-10pm)

Not Available

Required

Thursday *

Morning (8-11am)

Afternoon (11-2pm)

Late Afternoon (2-6pm)

Evening (6-10pm)

Not Available

Required

Friday *

Morning (8-11am)

Afternoon (11-2pm)

Late Afternoon (2-6pm)

Evening (6-10pm)

Not Available

Required

Saturday *

Morning (8-11am)

Afternoon (11-2pm)

Late Afternoon (2-6pm)

Evening (6-10pm)

Not Available

Required

Any other details about your availability?

If approved, when would you be interested in starting supervision? *

Supervision cohorts start on the 1st and 15th of every month

What frequency are you interested in? *

Full-Time Supervised Fieldwork (5% supervision for up to 130hrs fieldwork per month)

Part-Time Supervised Fieldwork (5% supervision for up to 80hrs fieldwork per month)

Full-Time Concentrated Supervised Fieldwork (10% supervision for up to 130hrs fieldwork per month)

Part-Time Concentrated Supervised Fieldwork (10% supervision for up to 80hrs fieldwork per month)

I'm not sure

How did you hear about ABC Behavior's supervision program? *

ABC Behavior website

BACB Website

Word-of-mouth

Google search

School

Other:

Required

Briefly describe you past experience working in the field of ABA. If you have no experience in this field, describe your current employment setting.

Why are you interested in pursuing your BCBA/BCaBA certification and what are your long term goals?

Why are you interested in receiving your supervision through ABC Behavior Training?

Is there anything else you'd like me to know?

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