Independent Licensed Clinician Careers Form (LCSW, LMFT, LPCC)

Full Name *

First Name

Last Name

Phone Number *

(###)

###

####

Preferred Contact Method

Email

Phone

Either

Are you currently under supervision for licensure hours?

Yes

No

Are you looking for clinical supervision?

Yes

No

Do you have experience with Employee Assistance Programs (EAP)?

Yes

No

Do you have a private practice or plan to start one?

Yes

No

Do you prefer Telehealth, In-Person, or a mix of both?

Telehealth

In-person

Both