Supervision with Cindy Rose, M.A., RP., CCTP - Intake Form

Thank you for your interest in supervision. Please complete this intake form to help me learn more about your goals and needs. After I receive your responses, I will reach out to discuss your interests in supervision in more detail. If we decide to move forward together, I will provide a contract and policy/procedures document for your review and signature to begin our supervision relationship. I look forward to the possibility of working with you.

Preferred Name (If Different)

Address (Please include postal code)

Permission to leave voice mail

Yes

Permission to text any updates

Yes

Permission to email

Yes

What form(s) of supervision are you looking to enter in with Cindy?

Individual Supervision Sessions

Dyadic Supervision Sessions - I have a partner already

Dyadic Sessions - I need a partner

4 HOUR GROUP SUPERVISION - Virtual, Friday, May 29 - 8:00 a.m. - Noon

Group Supervision - Virtual, Biweekly, Tuesday's @ 9:30 - 11:00 a.m.

Group Supervision - Virtual, Biweekly, Wednesday's @ 11:30 a.m. - 1:00 p.m.

Are there days / times of the week that generally work best for you for supervision sessions?

Please list your academic achievements in order of most recent to least recent. Please include the name of institution, graduation year, and major/minor

Do you have any other certifications or trainings (ie - CBT, DBT, ACT, ASIST, etc)

Please list your related experiences in order of most recent to least recent, including name of organizations/companies worked for, and time span worked:

Are you currently offering psychotherapy services to clients?

Yes

If yes, how many clients do you see on average per week and what ages/demographics do you generally work with?

Are you a member of:

What are your top three goals for clinical supervision?

What modalities of therapy are you currently using?

Anything else that would be helpful for me to be aware of?