Supervision Inquiry Form

Please complete the following form for initiating contact with me about supervision. Before contacting me, please review the rules around clinical supervision and make sure you meet requirements for LCSW supervision. Those can be found by reading Texas Administrative Code RULE §781.402, Clinical Supervision for LCSW and Non-Clinical Supervision for Independent Practice Recognition.

Name

First Name

Last Name

Email Address

Supervision Format Seeking

Individual

Group

Combo

Unsure

Have you accrued any clinical hours with another supervisor/plan? If so, please describe how many and reason for seeking new supervisor:

Do your job(s) meet criteria for clinical supervision?

Yes

Unsure

Describe your current job (setting, role) and clinical nature of job duties...

What are you seeking in a supervisor and in a supervision experience?

What are areas you seek to grow in professionally while under supervision?

Describe your experiences with past supervisors (at work, internship, etc...). What worked well? What was challenging for you?

Please share how to you came to find me, or who referred you:

I have read the Texas Administrative Code section on clinical supervision and understand the rules and requirements

Yes