Supervision Interest Form Supervision Interest Form Please enable JavaScript in your browser to complete this form.Thank you for your interest in beginning supervision with me. It’s important to find a supervisor who aligns well with your professional goals and provides the support you need on your path to licensure. Take the time to thoughtfully consider your specific needs and preferences for supervision, and provide detailed information in your responses. *ALL INTERESTED CANDIDATES MUST PROVIDE SERVICES TO INDIVIDUALS IN TEXAS ONLY. Professional ethics prohibits us from providing services in a state that we are not licensed. Supervision is an investment of $450 per month for the required 4 hours of supervision and on call Support for Crisis & Emergencies. Once your Interest Form has been submitted, I will be in contact with you to schedule a consultation to discuss what our supervisory relationship would entail. I am excited at the potential to be a part of your journey! Your DetailsName *FirstLastEmail *Phone *Position DetailsWhat type of supervision are you seeking? *NEW Texas LPC Associate SupervisionTransitioning LPC Associate SupervisionIf you are looking to become an LPC Associate, where are you in the process? Check all that apply. *Completed a Masters Degree or PhD in Counseling, Psychology, Family Therapy, or a related field from an accredited college or university as required by the Texas Behavioral Health Executive Council (BHEC) – State Board of Examiners of Professional CounselorsSuccessfully completed the National Counselor Exam (NCE)Successfully completed the Texas Jurisprudence ExamSecured proposed site(s) for obtaining clinical hoursI am still in my Master’s program but will graduate within the next 6 monthsI am scheduled to take my NCE within the next 6 monthsOther (please describe at the end of this form)What Master's level counseling program are you in or did you graduate from? *When would you like to start supervision? *Three broad goals for your supervision experience? *If you are already an LPC Associate, how many direct and indirect hours have you earned so far under supervisionWhere do you plan on acquiring hours towards your license at this time? *What areas of counseling are you most interested in and what has your experience been like so far? What treatment modalities/techniques do you use when working with clients?What other information is important for us to know?Do you have any questions we can answer to help you get started?References *Provide a list of 3 references (1 professor, 1 supervisor and 1 personal). Include first and last name, email address, phone number, relationship and length of relationshipSubmit a Resume * Click or drag a file to this area to upload. Upload Copy of Transcript that shows conferral date Click or drag a file to this area to upload. Upload Copy of NCE Score Displaying Proof of Passing Click or drag a file to this area to upload. Upload Proof of Passing Jurisprudence Exam Click or drag a file to this area to upload. Next Steps Someone from our team will reach out to you as soon as possible. We look forward to connecting with you! If you are not yet an LPC Associate, be sure to view the BHEC website with all necessary documentation in order to apply for licensure. Note: This is NOT an application for employment. This inquiry screen is ONLY to request LPC Supervision for the purposes of state licensure in Texas. Submit
