PA Licensure Supervision Interest Form

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This form is to express interest in LPC Supervision Services and to help me get a sense of if I am the best fit for you.

Please note that I do not become eligible to supervise until end of August 2024. However, you can submit interest and we can meet for consultations prior to this if you'd like. Information on pre-licensed discounts on that form.

Email *

Please state your legal name and pronouns, along with a different name you go by, if you have one.

(i.e. Rebecca Smith, she/her, but I go by Becky)

Are you Pre-LPC or LCSW? *

LPC

LCSW

What sort of clients/issues are you working with currently? *

What made you want to pursue supervision with Helsel Counseling? *

What do you most look forward to in supervision? What is important to you in supervision? *

What is important to you in a supervisor? What do you hope our relationship looks like? *

Is there anything you'd like me to know about you as a potential supervisee? *

Do you plan to get all of your hours with me or do you have another supervisor as well? *

Yes, I plan to get all of my hours with you at this time.

No, I plan to get another supervisor or already have one.

I'm not sure at this time.

If you have another supervisor, please list their name, credentials, and practice name below.

Also, if you do have or plan to have 2 supervisors simultaneously, please explain what you would like from me vs. them, how our roles intersect and differ, etc.

How many hours do you have currently? *

Please rank these statements in order of 1 (best describes you) to 4 (least describes you).

This helps me to understand how you prefer to be interacted with; also, to see how well our interaction styles mesh!

I like fast and direct information. I appreciate when we can quickly get to the point.

I like to have fun. I get bored and distracted easily.

I like community and purpose. Ask me about my personal life!

I want all the details. I love organization, spreadsheets, and the like!

Send me a copy of my responses.

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