Intake For Supervision
Thank you for reaching out.

We are glad that you decided to complete the training hours and pursuing the process of becoming certified.

Please fill out this form to know more about you and know how we can further support you.

Please check our website for more information or if you want to be part of our intensive ABA verified course sequence that meets the BACB and QABA requirements. This ongoing project provides a sustainable and affordable implementation in the country, https://btsconsulting.info/.

To know more about Maribel Castillo Stikeleather, please feel free to check https://www.maribelcastillo.co.

Email *
Today's Date *
MM
/
DD
/
YYYY
Complete Name   *
Date of Birth *
MM
/
DD
/
YYYY
Primary Reason for Referral (RBT; BCaBA; BCBA): *
Referral Source, who refers my name as a supervisor to you? *
Home address and contact number *
When and Where did you attend your 40 hour RBT training? For BCaBA / BCBA, please provide the school's (organization's) name. *
Are you currently working? *
If Yes, what is the name of the company / center that you are currently working for? *
Do you own a center that provides ABA services? If yes, what is the name of the company / center and location of your center? *
Do you work directly with individuals with special needs? *
If yes, How many clients? *
How many direct service hours (behavior-analytic services) do you provide per week? *
Other Comment: *
Do you consider distance coaching and supervision? *
Other Comment: *
There are specific requirements for supervision as per the BACB requirement. Have you read all this information? https://www.bacb.com/rbt/, https://www.bacb.com/bcaba/, https://www.bacb.com/bcba/ *
As RBT, are you considering pursuing your BCaBA or BCBA in the near future? *
Are you pursuing your BCaBA or BCBA? *
If you are pursuing your BCaBA or BCBA, when do you plan to sit for your BCaBA / BCBA exam? *
Are you aware about the recent changes to the BACB’s international certification? Reference: https://www.bacb.com/wp-content/uploads/2020/06/Recent-Changes-to-International-Focus_200520.pdf *
If yes, what is your plan dealing with the recent changes? *
So far, how many supervision hours have you accumulated? *
Are you willing to mentor another student to provide guidance on becoming an effective implementer using behavior analysis in the field? *
What are your expectations, and how can we best support you? *
Other Comment: *
Release and Consent: I hereby declare that I have read all supervision requirements and new announcements by the BACB. I understand that writing my initials means that all information I provided is correct to the best of my knowledge. *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms