Supervision Request Form Supervision Request Form PERSONAL INFORMATION Name Name First First Last Last Phone Email PRACTICE INFORMATION Name of Practice or Workplace * Location of Practice (city and province) Employment Type * Self-employed at own private practice Self-employed working for other group practice Student Agency OtherOther Type of Practice * VirtualIn-PersonHybridOther Type of Practice Number of years in practice (post-graduation) * THERAPEUTIC STYLE/PREFERENCES Please describe your philosophy/beliefs when it comes to therapy, and how you conduct yourself as a therapist: Check off any areas of interest or specialties * Addiction ADHD Adoption Alzheimer’s Anxiety Mood Disorders Personality Disorders Autism/ASD Behavioural Issues Career Counselling Chronic Illness/Pain Interpersonal Issues Disabilities Life Transitions Marital and Premarital Sexuality Gender Identity Issues Coming out Social Anxiety Polyamory Sex Therapy Obesity Parenting Pregnancy, Prenatal, Postpartum Racial/Cultural Identity School Issues Self-Esteem Depression Domestic Violence Eating Disorders Grief Infidelity Sexual Abuse Spirituality Sports Performance Trauma and PTSD Traumatic Brain Injury OtherOther OtherOther OtherOther Therapeutic Modality Preferences/Experience * ACT Adlerian ABA Art Therapy Attachment-Based Biofeedback Brainspotting CBT Cognitive Processing Compassion Focused DBT EMDR Emotion Focused Integrative Internal Family Systems Interpersonal Jungian Mindfulness-Based Motivational Interviewing Music Therapy Narrative Neurofeedback Person-Centered Play Therapy Prolonged Exposure Therapy Psychoanalytic Existential Experiential Therapy Family Systems Gestalt Gottman Method Humanistic Hypnotherapy Psychodynamic Reality Therapy Relational Solution-Focused Brief Therapy Somatic Strengths-Based Transpersonal Trauma Focused Age Demographics * <12 Years Old 12-15 Years Old 16+ 18+ Older Adults Elderly Session Types * Individuals Couples Poly Relationships Family Group Therapy Do you speak any languages besides English? * Any Special Demographics you Currently or Would like to Work with, or have experience with? (faith-based, LGBTQ+, ethnicity, etc.) Please provide any additional information you believe it would be important for us to have SUPERVISION Preferred Supervisor * Kayleen EdwardsJennifer LaneAny Why are you interested in supervision at Roots in Wellness with your preferred supervisor? * What type of supervision are you interested in? * Individual Dyadic (I have a partner) Dyadic (I don’t have a partner) Group OtherOther How frequently are you looking at engaging in supervision? * WeeklyBiweeklyMonthlyAs-NeededOther How frequently are you looking at engaging in supervision? Please indicate any and all supervision topics you’re interested in: * Administration Assistance Private Practice Questions Regulatory Body/Ethical Questions Marketing & Business Help Direct Observation Live Supervision Review of Session Recordings Safe and Effective Use of Self Case Consultation Case Studies Case Presentation by Supervisor Documentation Review Role Playing/Simulations Learning new skills/strategies Education on Various Topics What’s your Preferred Delivery Method for Supervision? * Video Phone In-Person Hybrid OtherOther What’s important to you in regards to the supervisor-supervisee relationship? * Please let us know any other information you think is important: COMPETENCY RATINGS Instructions: Knowledge of Modalities * 1 2 3 4 5 6 7 8 9 10 Case Conceptualization * 1 2 3 4 5 6 7 8 9 10 Empathy and Understanding * 1 2 3 4 5 6 7 8 9 10 Building Rapport * 1 2 3 4 5 6 7 8 9 10 Flexibility * 1 2 3 4 5 6 7 8 9 10 Ethical Practice * 1 2 3 4 5 6 7 8 9 10 Time Management * 1 2 3 4 5 6 7 8 9 10 Objectivity * 1 2 3 4 5 6 7 8 9 10 Safe and Effective Use of Self * 1 2 3 4 5 6 7 8 9 10 Comments: AVAILABILITY Day of the Week * Sunday Monday Tuesday Wednesday Thursday Friday Saturday Times * Mornings Afternoons Evenings OtherOther Additional Availability Info SUPPORTING DOCUMENTS Please upload your resume/CV here * Drop a file here or click to upload Choose File Maximum file size: 516MB Liability Insurance Copy * Drop a file here or click to upload Choose File Maximum file size: 516MB College Registration Certificate * Drop a file here or click to upload Choose File Maximum file size: 516MB If you are human, leave this field blank. Submit Δ Share this:TwitterFacebookLike this:Like Loading...