Supervision

Thank you for exploring Clinical Supervision with Tilia Therapy.  In order to arrange a first session with a supervisor, please complete the following form. If you have any further questions, please don't hesitate to get in touch with Ali Xavier: ali@tiliatherapy.co.uk

When you contact us with an enquiry about Tilia Therapy we will collect information to help us satisfy your enquiry. This will include your basic contact details and an emergency contact. (You might wish to inform your emergency contact that you have provided their details to us).. 

If you decide not to proceed with supervision we will ensure all your personal data is deleted within two weeks. If you would like us to delete this information sooner, just let us know.

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Email:
Title:
Full name:
Gender:
Preferred pronouns:
Address:
Date of Birth:
MM
/
DD
/
YYYY
Phone number:

Emergency contact: (name and contact number, provided in case of an emergency during a supervision session)

Are you a:
Clear selection
If you are in training, please provide details of your training provider:
Supervisees are required to be members of a professional body (BACP, UKCP, NCS, ACC).
Membership body and membership number:
Supervisees are required to hold personal indemnity insurance. Insurance provider and policy number: (please indicate if insurance is provided by a placement)
Do you hold a professional /clinical will?
Clear selection
Please provide an overview of your current practice circumstances (agency / private
practice, a particular client group you work regularly with, presenting problems that
frequently come into the therapeutic space):
How much supervision do you require per calendar month?
What days and times would be be available for supervision?
Is there any other information you’d like to make known to us?
Submit
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