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Clinical Supervision interest form
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* Indicates required question
Full name
*
Your answer
Email address
*
Your answer
Phone number
*
Your answer
What clinical setting are you practicing at?
*
Private practice
College/university
Non-profit
Other:
Required
How often would you want to meet for supervision?
*
Weekly
Bi-weekly (every other week)
Other:
How would you describe your clinical modalities that you use in your practice currently? If there are others you'd like to learn more about, please share.
*
Your answer
What are some hopes you have from clinical supervision? Please also share what makes you want to work with me.
*
Your answer
What rate range do you fall into?
*
Students only - $30-50
Solidarity - $60-80
Sustain - $90-110
Full rate - $120-150
Redistribution - $160-200
What is your licensure type? (MHC-LP, LMHC, LCSW, LMFT)
*
Your answer
Please share anything else that you would like me to know
Your answer
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