Request Licensure Clinical Supervision

Supervision Request Note: After you submit, I will reach out to schedule a brief consultation to confirm fit, review your licensure plan, and set a start date.

1Clinician Information

Full Name *

Email Address *

Phone Number *

Town / City *

2Licensure Track

Current Credential *

Maine License Number *

Supervision Hours Completed

Supervision Hours Still Needed

Target Licensure Date

Do you currently have a supervisor?

NoYes, replacingYes, adding

3Supervision Format

Which format(s) are you interested in? *

Weekday, business hoursIndividual Supervision$150 / hourWeekend premium schedulingIndividual Supervision$200 / hourSmall peer cohort, limited seatsGroup Supervision$60 / hour per participant

Preferred Frequency

Preferred Modality

Availability

Weekday morningsWeekday afternoonsWeekday eveningsWeekends

4Current Practice & Goals

Agency / Employer

Primary Practice Setting *

Areas you want to strengthen

Describe your current caseload *

What do you want from supervision?

5Acknowledgment & Consent

I understand individual supervision requires at least 24 hours' notice to reschedule or cancel, and missed sessions without notice are billed at the full rate.I understand group supervision seats are limited and missed group sessions cannot be made up or refunded.I acknowledge that supervision is private pay and I accept financial responsibility for session fees.I attest that the credential and licensure information in this form is accurate to the best of my knowledge.

Signature (Type Full Name) *

Date *

Licensure Clinical Supervision Request Form

1Clinician Information

2Licensure Track

3Supervision Format

4Current Practice & Goals

5Acknowledgment & Consent