You Are Worthy: Therapy, Training & Consultation

Name *

First Name

Last Name

Phone

(###)

###

####

Estimated Number of Supervised Hours Completed *

0-900

900-2,000

2,000-3,000+

3,000 hrs but less than 104 weeks of supervision

I don’t know

W2 Employee *

Yes

No

Volunteer

Yes

No

Do you have an individual clinical supervisor?

Yes

No

Do you have a copy of active liability insurance to provide? *

No

Times I am available to attend the group *

Monday 12:30-2:30

Tuesday 10 AM-12 PM

Wednesday 12:00-2 PM

Friday 8:30-10:30 AM

Friday 10 AM-12 PM