LMFT Supervision Discovery FormWe’d love to learn more about your supervisory needs and vision for your professional development. Open Form LMFT-A Supervision Discovery Form Name * First Name Last Name Email * Phone (###) ### #### Please list all urls for your web and social media presence. * Educational History What is your highest degree earned? * High School Masters Doctoral Degree Other What school(s) have you attended and what degree did you earn at each school? * Have you successfully passed the AMFTRB? * Yes No Other Practice Preference What age groups do you prefer working with and why? * Is there a disorder or presenting issue that you are most comfortable working with and why? * Is there a particular issue that you know youd be uncomfortable working with for example working with a person with a particular diagnosis or presenting issue? * Is there a particular issue that you know you'd be uncomfortable working with for example working with a person with a particular diagnosis or presenting issue? * What theories and modalities are you most drawn to? * What therapy modalities would you like to explore and learn more about? * The services I prefer to provide are: * Check all that apply Individual therapy Couple's therapy Family therapy Group therapy Other Have you ever personally been to therapy? If yes, how long did you work with your therapist? If no, are you interested in going to therapy? * Previous Experiences Are you currently being supervised by another supervisor? * Yes No If you answered no to the above question have you worked with an LMFTsupervisor in the past? Yes No N/A Previous Supervisors Contact Details * Please list the name, email, phone and license # of all previous supervisors. Consent to Contact Your Previous Supervisor * I understand that you may contact my previous supervisor and I give consent for you to contact my previous supervisor. Consent is required if you have worked with an LMFT-S before. Looking Ahead I'm ready to begin supervision... * Within the next week. Between one to three months from now. Three to six months from now. Six months or more from now. Please describe your plan to obtain clinical hours. * Do you have a clinical site? Are you in private practice? I'll know I've been successful as a therapist when... * Please complete the sentence above. I'll know I've failed as a therapist if... * What has to happen to make you feel you failed? In 3 words or less, how would you describe yourself as a person? * Thank you for your interest in supervision. We will be in touch with you shortly to discuss next steps.Trillion Small, PhDFounder/CEO
