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Supervision Registration
**If you do not get a response in 3-5 business days please check your spam/junk folder before following up.**
*
Indicates required field
Name (that will be on your license)
*
First
Last
Name we should use (if different)
*
First
Last
Email
*
Phone Number
*
Pronouns
*
If you feel comfortable, please write which pronouns we should use when addressing you.
Type of supervision
*
Select
Individual
Group- I have people I want to be in group with
Group- Will join any group
Open to group or 1:1
Upload your resume
*
Max file size: 20MB
Not required, but helps me to see if I will be a good match for you as a supervisor.
Referral source
*
Select
Social Media
Google Search
Psychology Today
Colleague / Personal
Professional License Association (ex: NASW)
College- Please specify
Employer - Please specify
Other (please explain below)
Why? This helps us see where people are finding us so we can determine where to place our resources to help become more visible.
Explain
*
What State are you getting licensed in
*
Select
Illinois
Wisconsin
Other
What days and times are you available? Include how frequent you need supervision. Please be as specific as possible.
*
What is your employment status
*
Employed or contracted by a non-profit
Employed or contracted by a hospital/health clinic
Self-Employed
Employed or contracted by a private practice
Employed or contracted somewhere not listed
Not currently Employed or contracted in my field.
What is your current license(s)
*
LCSW
APSW
LPC
LPC-IT
LMFT
LMFT-IT
Other
Submit
Home
Meet Us
Contact
Location
New Adult Client form
New Minor Client form
crisis response services
Supervision Registration
About
Office FAQs
Our Mission
Blog
Investment in you
Current Clients
Fundraiser
