Supervision and Consultation Interest Form
Hello! 

Thank you for your interest in my supervision (pre-licensure folks will be referred to as supervisees) and consultation group (licensed folks will be referred to as consultees). A bit about the group:

General Info
- This group will be starting sometime in June, potentially July, depending on when there are enough people to start. I plan on starting when there are at least three members who plan on joining.
- The group will be a minimum of three members and a maximum of 6 members. O
- The theoretical approach of the group will be eclectic (ie., CBT, psychodynamic, humanistic, solution-focused) and lean towards more pragmatic contemporary psychodynamic theory and practice.
- The structure of the group will be that half of the group will present a case or professional issue they would like to discuss. Depending on time, each person presenting will get relatively equal time to discuss their case/professional issue.
- Members who have urgent/emergent issues will be asked to present first even if it is not their designated time to present.
- The general focus within the group should be evidence-based practice, cultural humility, case conceptualization, therapy skill development, countertransference management, and professional identity development.
- Dr. Schultz's role will be to provide supervision/consultation (ie., using teaching, consulting, and therapy skills) while also facilitating interpersonal learning within the group. One of the main benefits of group supervision/consultation is getting feedback both from the group leader as well as the group members who are often in similar places professionally.
- Members are highly encouraged, though not required, to bring in tapes or transcripts of their sessions, when they have permission from their clients. 

Pre-Licensure Supervision Info
- This is not a group for supervisees who are not seeking licensure. 
- Supervisees needing paperwork filled out for licensure will need to bring this to Dr. Schultz's attention, including discipline specific policies and paperwork requirements. This should be discussed before the group commences so that there is a mutual understanding that of what is required regarding paperwork/supervision and that Dr. Schultz fits the requirements for supervision. 
- All pre-licensure supervisees must notify each of the clients, in writing, that they are in supervision with Dr. Schultz (including contact information). This form will require clients who sign it to consent to a release of information so that supervisees may talk about their work in the group. This can be provided by Dr. Schultz if necessary. 
- Please note that some pre-licensure supervision requires the provision of therapy sessions to be reviewed by the supervisor. In this case, members are required to provide one taped recording per month to meet this requirement.
- Supervisees will be required to meet with Dr. Schultz on a quarterly basis to discuss, as required by pre-licensure supervision, their progress, supervision objectives/goals, and strengths and areas of improvement.  This will be a separate meeting from the group to be charged at $25/half hour. A written report of this evaluation will be provided. 

Consultation Info
- Consultees must have a license
- Consultees, as licensed professionals, retain full ethical/legal responsibility for their work with clients. 
- Consultees are not required to have an individual supervisor to participate in this group.


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This group welcomes both licensed and unlicensed folks working towards licensure. Which of the following describes you?
Which of the following describes your professional discipline (based on your graduate school education)?
If you are unlicensed and planning on using this group for your licensure supervision, you are required to have an individual supervisor in place (prior to the group starting) that you would have to provide consent for me to collaborate with them, when necessary, regarding your work with clients. Please check which best describes you:
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The group will be meeting Monday late afternoon/early evening. Time will depend on participant interest. Which of the following times work for you? 
In terms of location, there are two possibilities: Virtual or in-person in Dr. Schultz's home in Fishtown (15 minute walk from MFL line). What is your preference regarding location of the supervision group?
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