Westminster Counseling Program - Site Supervisor Verification Form

We require that site supervisors complete this form. Thank you!

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* 1. Please provide your contact information

Name

Site Name

Site Street Address

Site City, State, and Zip Code

Your Email Address

Your Work Phone

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* 2. What graduate degree do you hold?

Masters in Clinical Mental Health Counseling (formerly Professional Counseling)

Masters in Clinical Social Work

Masters in Marriage and Family Counseling

Masters in Nursing

Doctorate in Counselor Education & Supervision

Doctorate in Psychology

Doctorate in Marriage and Family Therapy

Other (please specify)

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* 3. What license do you hold?

Clinical Mental Health Counselor

Clinical Social Worker

Marriage and Family Therapist

Psychiatric Nurse Practitioner

Psychologist

Other (please specify)

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* 4. For how many years have you been licensed?

Less than 2

2-5 years

6-10 years

>10 years

Other (please specify)

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* 5. For how many years have you been working with the population/issues that are present at your site?

Less than 2 years

2-5 years

6-10 years

>10 years

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* 6. For how many years have you supervised master's level mental health trainees? (Practicum, Internship, Associates)

Less than 2 years

2-5 years

6-10 years

>10 years

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* 7. Please describe any coursework, continuing education sessions, reading, or other training you have had in supervision.

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* 8. Supervisors of our practicum students are required to either record or directly observe the student's work with clients at some point during practicum (we recommend especially in the early stages). Supervisors of interns are strongly encouraged to do so also. Are you prepared to do this?

Yes

Comment

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* 9. Please upload a copy of your CV or resume here.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 10. Please upload a picture or a copy of your current license

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 11. Please verify that you have completed all the components of the site supervisor training posted on the Westminster MSMHC website.

Yes, I completed the training

Other (please specify)

Thank you for supervising our student. Please contact us if you have any questions or concerns. We look forward to working with you.