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 * First Last
Site 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. *
Yes No
Job Title *
I earned a minimum of a masters degree in counseling or a related educational field (e.g. psychology, social work, psychiatry, etc.) *
Yes No
If Yes, please identify the name of the degree and the university from which you earned it. *
I completed training in counseling supervision (e.g. graduate-level course, workshop, continuing education training, etc.). *
Yes No
If Yes, please identify the full title of the course or training and the source that provided it.
I have worked at this site for a minimum of two years. *
Yes No
Site Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Work Phone * - ### - ### ####
Fax - ### - ### ####
Work Email *
Site Web Site
Certifications/ Licenses *
Provisionally Certified School Counselor Permanently Certified School Counselor Licensed Mental Health Counselor Licensed Clinical Social Worker Licensed Clinical Psychologist Nationally Certified Counselor Nationally Certified School Counselor Nationally Certified Clinical Mental Health Counselor CASAC-T CASAC Other