Clinical Supervision Group Application

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Please complete this application to participate in the clinical supervision group at The Clarity Couch. Your participation will include 3 training supervision hours each month, clinical case consultation and completion of required paperwork for The Ohio Counselor Social Work, Marriage and Family Therapy Board. There are 8 spots available in this group format and participants are eligible for additional individual supervision upon request. Supervision is offered at a rate of $60.00 per group or at a discounted rate of $100 per month.

Group will meet, virtually, and is offered on the First and Third Monday of each month from 9:30-11:00 am. Please complete this form to initiate the application process. Contact admin@theclaritycouch.com if more information is needed.

Email *

Full Name *

DOB *

YYYY

Home Address *

Phone Number *

Preferred Method of Contact *

Call

Current License *

LPC

Counselor Trainee

LPCC

Other:

Ohio License Number *

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