Clinical Supervision Questionnaire
Please complete all questions and you will be contacted to schedule an intake.
First and Last Name *
Email Address (please do not put your work email) *
State where you are seeking Licensure *
Required
Select which license you need supervision hours for *
Required
Did you start clinical supervision with someone else? *
Required
If yes, please explain why you are seeking a new Clinical supervisor.
Are you seeking in person or online (in person cannot be guaranteed due to COVID 19) *
Do you have a "Coaching" certification (Life, etc)? *
Do you have personal Liability insurance? (This will be required) *
Are you willing to add me to your personal liability insurance as your supervisor? (This will be required) *
Days/Times you are available for a 30 min intake *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy