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Clinical Supervision Questionnaire
Please complete all questions and you will be contacted to schedule an intake. **If you are employed with the NYC Department of Education I will not be able to supervise you**.
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* Indicates required question
First and Last Name
*
Your answer
Email Address (please do not put your work email)
*
Your answer
State where you are seeking Licensure
*
NY
NJ
Both
Other state
Required
Select which license you need supervision hours for
*
LCSW
R (NY)
LMHC
Required
Did you start clinical supervision with someone else?
*
Yes
No
Required
If yes, please explain why you are seeking a new Clinical supervisor. (please indicate how may hours you need to complete the requirements).
Your answer
Are you seeking in person or online (in person cannot be guaranteed due to COVID 19)
*
In person
Online
Do you have a "Coaching" certification (Life, etc)?
*
Yes
No
Do you have personal Liability insurance? (This will be required)
*
Yes
No
Are you willing to add me to your personal liability insurance as your supervisor? (This will be required)
*
Yes
No
Days/Times you are available for a 30 min intake (please provide days and times)
*
Your answer
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