Clinical Supervision Inquiry

Thank you for your interest in clinical supervision at Milton’s Place.

Supervision is currently offered for LLPC and LLC clinicians located in Michigan who are working toward full licensure.

Please complete the form below to help determine supervision fit and availability. If supervision openings are available, you will be contacted to schedule a consultation.

Contact Information

Full Name

Phone

City in Michigan

Licensure Information

Current License Status

License Number (if applicable)

Date License Was Issued

Month

Day

Year

Graduate Program

Graduation Year

Employment Information

Current Employer / Practice Name

Employment Type

Approximate Weekly Client Caseload

Supervision Needs

Type of Supervision You Are Seeking

Individual Supervision

Group Supervision

Either Option

When Are You Hoping to Begin Supervision?

Preferred Supervision Times

Weekday mornings

Weekday afternoons

Weekday evenings

Other

Professional Development

What are you hoping to gain from supervision?

What clinical populations do you currently work with?

Is there anything specific you would like support with in supervision?

I understand supervision is offered for clinicians located in Michigan and may require verification of licensure status.

Milton's Place

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