Supervision Inquiry Form

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Name*

Phone number*

Email address*

Current work site*

Do you have an on-site supervisor?*

Yes

No

Are you seeking Licensed Professional Counseling or Art Therapy Supervision?*

LPC

ATR

Both

What populations are you currently working with?*

Where do you feel you are needing the most support in your growth as a professional?*

What are your strengths with your population?*

What are your strengths as a therapist?*

What are your strengths as a professional?*

How do you feel I could best serve you?*

What frequency are you hoping for?*

Weekly

Bi-weekly

Monthly

Are you interested in group supervision or individual?*

Group supervision

Individual supervision

Both

Are you interested in in-person or telehealth?*

In-person

Telehealth

Both

What days and times are you free?*

Do you have any questions for me?

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