Are you registering as a Supervisor or Supervisee?
Supervisor Supervisee
Full Name:
E-mail:
Phone:
Address (Street/City/State/Zip):
Type of License:
Degree:
Website:

List your Education:

List your professional experience:

To register as a Supervisor:

Please list your area(s) of Specialization:

Briefly describe your supervision orientation/style:

What types of services are you offering? Please specifically address where you wish to provide service (are you willing to travel? Are you offering consultation at your own office?) when (what days/hours?) and how (individual vs. group supervision):

Fee requirements (please indicate any pro bono, sliding scale, student rate or other arrangements, as appropriate):

To register as a Supervisee:

Please list your area(s) of interest, specialization or study:

Briefly describe what type of supervision you are seeking (client types, skills, specialization areas, licensure):

What types of services are you seeking? Please specifically address where you would like the service (are you willing to travel? Do you require on-site supervision?) when (what days/hours?) and how (individual vs. group supervision, do you represent a facility, or an individual?):

Payment (please indicate any special arrangements, as appropriate):

OTHER - For Supervisors or Supervisees:

We will post your information on our website within 1 week.