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Supervision or Consultation Questionnaire
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Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
City
*
Your answer
State/ Province
*
Your answer
Phone Number
*
Your answer
Email
*
Your answer
Do you need supervision or consultation?
*
No
Yes
Student
Clinician
Required
Are you interested in practicum/ internship? If so what school do you attend?
*
Your answer
Are you applying for PLCP and need a supervisor? Or are you currently at PLPC and want to change supervisors? If making a change please explain why.
*
Your answer
How long until graduation if student? If not a student when would you like to change supervisors.
*
Your answer
Why are you choosing Crystal Clear Counsel?
*
Your answer
What are you current goals?
Your answer
Do you need to consult? If so what is the case?
*
Your answer
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