NC LCSWA Clinical Supervision Interest Form
Thank you for your interest in clinical supervision with Ceara Corry. 

Please complete this form thoroughly to help me prepare for our introductory call. 

After completing this form, you will be contacted at the email address provided to schedule our intro call. 

If you have any questions or difficulty completing the form, please email me at cee@ceethesexlady.com 
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Email *
Legal First and Last Name *
Preferred Name (if different from legal name)
Pronouns
Email Address *
Phone Number *
City and State you live in *
Are you currently employed in a clinical social work role?  *
If yes, where do you currently work?  If no, please write "n/a" *
Do you currently have a clinical supervisor through your workplace?  *
Do you currently have a clinical supervisor outside your workplace?  *
What kind of clients are you currently working with?  What kind of clients would you like to serve? *
What are your goals for supervision? *
What type of supervision are you interested in? *
Required
What is your desired start date? *
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Are there any specialities or specific modalities you're interested in? (CBT, EFT, sex therapy, couples therapy, family therapy, grief, anxiety, etc.)  *
The standard rate for supervision is $65 per hour for individual supervision (save 10% by paying $234 for 4 session at a time).  and $50 per hour for group supervision sessions (2-3 hours long). 

Are you in need of financial assistance to make supervision affordable for you? 

(note: financial assistance is not guaranteed). 
 *
Do you have any questions for me?
A copy of your responses will be emailed to the address you provided.
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