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Site Supervisor information Form

The purpose of this form is to gather information relevant for our interns and to ensure our seamless contact throughout the internship experience.

  • Name Name *
  • I completed this form within the last six months, and my information has not changed. If Yes, please click submit. If No, please complete the remainder of this form. *
    I completed this form within the last six months, and my information has not changed. If Yes, please click submit. If No, please complete the remainder of this form.
  • I earned a minimum of a masters degree in counseling or a related educational field (e.g. psychology, social work, psychiatry, etc.) *
    I earned a minimum of a masters degree in counseling or a related educational field (e.g. psychology, social work, psychiatry, etc.)
  • I completed training in counseling supervision (e.g. graduate-level course, workshop, continuing education training, etc.). *
    I completed training in counseling supervision (e.g. graduate-level course, workshop, continuing education training, etc.).
  • I have worked at this site for a minimum of two years. *
    I have worked at this site for a minimum of two years.
  • Site Address Site Address *
  • Work Phone Work Phone * - -
  • Fax Fax - -
  • Certifications/ Licenses *
    Certifications/ Licenses
  • Draw or Type
    I understand this is a legal representation of my signature. Clear
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