Clinical Supervision Inquiry Form

Full Name *

First Name Last Name

E-mail *

Phone Number *

Area Code Phone Number

What type of supervision are you seeking? *

NEW LPC Associate Supervision Transitioning LPC Associate Supervision None; Seeking contract employment opportunities only

Do you have a professional counselor identity? *

Yes No Unknown

What is/are your theoretical orientation(s) you have a passion for and why? *

Did you attend a CACREP University? *

YES NO

Have you or when will you complete your NCE Exam? If not, what date do you expect to sit for your exam? *

Do you have a clinical site in mind (Please specify if applicable)? *

Are you interested in joining Counseling Connections of San Antonio/Franklin Training & Consulting, Inc (Group Practice) [Optional for LPC Associates]? *

YES NO MAYBE OTHER

When are you seeking to apply for licensure? *

References (Please list three references with name, email address, and phone): *

NOTE: DO NOT USE FRIENDS OR FAMILY.

Best day/time to be contacted?

Month Day Year Hour Minutes AM/PM Option

Upload Resume *

Note: This is NOT for employment. This inquiry screen is ONLY to request LPC Supervision for the purposes of state licensure in Texas.

Additional Resources:

Supervisor(s):

https://www.psychologytoday.com/us/therapists/supervision-services

Military Spouses (Supervision Reimbursement):

https://www.militaryfamily.org/licensing-certification/

Veterans (Licensing Exam Reimbursement):

https://www.vba.va.gov/pubs/forms/VBA-22-0803-ARE.pdf