Please complete this short survey.

The information you share will be included on a list of DHP-approved LPC/LCSW Supervisors and provided on a request-only basis to applicants for the Virginia Health Care Foundation’s Boost! initiative. This pilot program is designed to accelerate licensure of Supervisees of Social Work and Residents in Counseling by paying for required hours of supervision.

To learn more about Boost!, please visit vhcf.org/Boost200

Questions? Click here to submit your questions.

Thank you for participating!

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* 1. Name (First, Middle Initial, Last) 

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* 2. I am a:

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* 3. I am a Virginia Department of Health Professions (DHP)-approved Supervisor.

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* 4. Please put your preferred contact information below.

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* 5. Virginia Locality of Practice (Primary) 

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* 6. Virginia Locality of Practice (Secondary) (If applicable)

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* 7. I provide Supervision:

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* 8. I provide:

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* 9. I charge the following per hour of Supervision:

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* 10. If your Supervision rate varies or additional clarification is required, please provide details here. Please limit to 200 words or less. 

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* 11. My clients are primarily (Select all that apply):

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* 12. You are welcome to include other information about you/your practice that might be helpful to Supervisees/Residents. Please limit response to 200 words or less. 

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* 13. By submitting this form, I am providing consent to the Virginia Health Care Foundation to make the information I have provided available on a request-only basis to Boost! applicants looking for a Supervisor.

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