{"id":4289,"date":"2019-09-18T16:37:30","date_gmt":"2019-09-18T20:37:30","guid":{"rendered":"https:\/\/drsonjasutherland.com\/?page_id=4289"},"modified":"2024-03-11T20:16:13","modified_gmt":"2024-03-12T00:16:13","slug":"clinical-supervision-form-individual","status":"publish","type":"page","link":"https:\/\/drsonjasutherland.com\/counselors-corner\/supervision-services\/clinical-supervision-form-individual\/","title":{"rendered":"Clinical Supervision Form &#8211; Individual"},"content":{"rendered":"<div class=\"brz-root__container brz-reset-all\">\n<section id=\"kvuvwmzant\" class=\"brz-section brz-css-hqDtc brz-css-sGxr0\">\n<div class=\"brz-section__content brz-section--boxed brz-css-lGcvB brz-css-hQaSX\" data-brz-custom-id=\"sgckksdwcl\">\n<div class=\"brz-bg\">\n<div class=\"brz-bg-image\"><\/div>\n<div class=\"brz-bg-color\"><\/div>\n<\/div>\n<div class=\"brz-container brz-css-qwa2g\">\n<div id data-brz-iteration-count=\"1\" class=\"brz-css-klRCe brz-css-hIu4T brz-wrapper brz-animated brz-css-uur3H brz-css-oyTwO\" data-animationid=\"viubdhyefi\">\n<div class=\"brz-rich-text brz-rich-text__custom brz-css-nETzh\" data-brz-custom-id=\"fqoohjguyi\">\n<div data-brz-translate-text=\"1\">\n<p class=\"brz-lh-xs-1_3 brz-tp-heading1 brz-text-xs-center brz-text-lg-center brz-fs-xs-45 brz-css-gQjjG\"><span class=\"brz-cp-color8\">Individual Supervision<\/span><\/p>\n<\/div>\n<\/div>\n<\/div>\n<div id class=\"brz-css-klRCe brz-css-sZoNe brz-wrapper\">\n<div class=\"brz-rich-text brz-rich-text__custom brz-css-nETzh\" data-brz-custom-id=\"mfzujrflrjseddkyoswcwdcynaewikttrehf\">\n<div data-brz-translate-text=\"1\">\n<p class=\"brz-tp-paragraph brz-text-lg-center brz-css-ycMno\"><span class=\"brz-cp-color8\">Indicate your choice of supervision services from the options below.<\/span><\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"brz-wrapper-clone brz-css-x_5ga\">\n<div class=\"brz-d-xs-flex brz-flex-xs-wrap brz-css-s1e42\" data-brz-custom-id>\n<div class=\"brz-wrapper-clone__item\" id=\"pongvelzypnfrntaoamwctbhjqvbfksziivu\">\n<div class=\"brz-icon__container\" data-brz-custom-id=\"pongvelzypnfrntaoamwctbhjqvbfksziivu\"><a class=\"brz-a brz-anchor\" href=\"#ydrbamtztfvosjjknzvkrfyndfxwikevlucz\" target=\"_self\" rel=\"noopener\" data-brz-link-type=\"anchor\"><span class=\"brz-icon brz-span brz-css-ss3_n brz-css-a8zaz\"><\/span><\/a><\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id class=\"brz-css-klRCe brz-css-uBZ9_ brz-css-nId0b brz-wrapper\">\n<div class=\"brz-spacer brz-css-xDp0R brz-css-z_o_k\"><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/section>\n<section id=\"ssvcqudnupwjfupcdosqadxivllscxnvqewr\" class=\"brz-section brz-css-hqDtc\">\n<div class=\"brz-section__content brz-section--boxed brz-css-lGcvB brz-css-sCQSo\" data-brz-custom-id=\"hhhxocdvehvynczivztzbpnudpogfewnoagb\">\n<div class=\"brz-container brz-css-qwa2g\">\n<div id class=\"brz-css-klRCe brz-css-uBZ9_ brz-wrapper\">\n<div class=\"brz-spacer brz-css-xDp0R brz-css-dHNeU\"><\/div>\n<\/div>\n<div class=\"brz-row__container brz-css-y69mh\" data-brz-custom-id=\"febzswiqcqjygilyumdwcngebrgmeroiivsh\">\n<div class=\"brz-bg\"><\/div>\n<div class=\"brz-row brz-css-seL9c brz-css-vtO2b\">\n<div class=\"brz-columns brz-css-t5Wdp brz-css-dHqUm\" data-brz-custom-id=\"gggegorjtunkzjjcnlserhizubavwgjjtpkl\">\n<div class=\"brz-bg\"><\/div>\n<div class=\"brz-column__items brz-css-gFHXL brz-css-xaai3\">\n<div class=\"brz-row__container brz-css-y69mh\" data-brz-custom-id=\"hvlvycqaggbvazwcghwxohsusjijzlnltjbl\">\n<div class=\"brz-bg\"><\/div>\n<div class=\"brz-row brz-row--inner brz-css-seL9c brz-css-vtO2b\">\n<div class=\"brz-columns brz-css-t5Wdp brz-css-aGvjx\" data-brz-custom-id=\"dsvxkiiidhedwqlfsigespapfapqwifcngii\">\n<div class=\"brz-bg\"><\/div>\n<div class=\"brz-column__items brz-css-gFHXL\">\n<div id class=\"brz-css-klRCe brz-wrapper\">\n<div class=\"brz-rich-text brz-rich-text__custom brz-css-nETzh\" data-brz-custom-id=\"wfzgtkwrhftstaajxcuctsmehrgzvxeoalzz\">\n<div data-brz-translate-text=\"1\">\n<p class=\"brz-tp-paragraph brz-css-ttzor\"><strong class=\"brz-cp-color1\">Supervision Options: <\/strong><\/p>\n<p class=\"brz-tp-paragraph brz-css-rwo7S\"><span class=\"brz-cp-color4\">Individual Supervision<\/span><\/p>\n<p class=\"brz-tp-paragraph brz-css-zaghe\"><a class=\"brz-cp-color7 link--external\" href=\"\/supervision-services\/clinical-supervision-form-triadic\/\" data-brz-link-type=\"external\">Triadic Supervision<\/a><\/p>\n<p class=\"brz-tp-paragraph brz-css-j5z9K\"><a class=\"link--external brz-cp-color7\" href=\"http:\/\/drsonjasutherland.prattis.com\/counselors-corner\/supervision-services\/clinical-supervision-form-group\/\" data-brz-link-type=\"external\">Group Supervision<\/a><span class=\"brz-cp-color7\"> <\/span><\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"brz-columns brz-css-t5Wdp brz-css-t8I0G\" data-brz-custom-id=\"teczklzbkzsdafpahhpobbejqrenqgyeigtk\">\n<div class=\"brz-bg\"><\/div>\n<div class=\"brz-column__items brz-css-gFHXL\">\n<div id class=\"brz-css-klRCe brz-wrapper\">\n<div class=\"brz-rich-text brz-rich-text__custom brz-css-nETzh\" data-brz-custom-id=\"lfkgrikaubennwhmiowirgmvwkjoakuuwoqb\">\n<div data-brz-translate-text=\"1\">\n<p class=\"brz-text-xs-center brz-tp-paragraph brz-css-bk0Un\"><a class=\"link--external brz-cp-color7\" href=\"http:\/\/drsonjasutherland.prattis.com\/counselors-corner\/\" data-brz-link-type=\"external\"><strong>Dr. Sonja Sutherland<\/strong><\/a><strong class=\"brz-cp-color7\"> \/ <\/strong><a class=\"link--external brz-cp-color7\" href=\"http:\/\/drsonjasutherland.prattis.com\/counselors-corner\/\" data-brz-link-type=\"external\"><strong>Counselors Corner<\/strong><\/a><strong class=\"brz-cp-color7\"> \/ <\/strong><a class=\"brz-cp-color7 link--external\" href=\"http:\/\/drsonjasutherland.prattis.com\/counselors-corner\/supervision-services\/\" data-brz-link-type=\"external\"><strong>Supervision Services<\/strong><\/a><strong> \/ Individual Supervision <\/strong><\/p>\n<\/div>\n<\/div>\n<\/div>\n<div id class=\"brz-css-klRCe brz-wrapper\">\n<div class=\"brz-embed-code brz-css-dncjj\" data-brz-custom-id=\"txyatpfykqdysdfnjuhrluiffalsztzeaqau\">\n<div class=\"brz-embed-content\">\n<div>\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2007-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/wp-json\/wp\/v2\/pages\/4289#wpcf7-f2007-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"2007\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2007-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<p><span class=\"orang\">*<\/span> indicates required field\n<\/p>\n<p><b>Sessions must be completed within a consecutive 12-month period.<\/b>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"supervision-option\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"supervision-option\" value=\"1 - 55 min session per mo. (1st or 3rd week of the mo.) $100 per session. 12 payments auto-billed @ $100 per mo.\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">1 - 55 min session per mo. (1st or 3rd week of the mo.) $100 per session. 12 payments auto-billed @ $100 per mo.<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"supervision-option\" value=\"2 - 55 min sessions per mo. (1st &amp; 3rd weeks of the mo.) $80 per session. 12 payments auto-billed @ $160 per mo.\" \/><span class=\"wpcf7-list-item-label\">2 - 55 min sessions per mo. (1st &amp; 3rd weeks of the mo.) $80 per session. 12 payments auto-billed @ $160 per mo.<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"supervision-option\" value=\"2 - 75 min sessions per mo. (1st &amp; 3rd weeks of the mo.) $100 per session. 12 payments auto-billed @ $200 per mo\" \/><span class=\"wpcf7-list-item-label\">2 - 75 min sessions per mo. (1st &amp; 3rd weeks of the mo.) $100 per session. 12 payments auto-billed @ $200 per mo<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<div class=\"form-row\">\n\t<div class=\"column-half\">\n\t\t<p><label> First Name <span class=\"orang\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"first-name\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column-half col-righ\">\n\t\t<p><label> Last Name <span class=\"orang\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"last-name\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"form-row\">\n\t<div class=\"column-half\">\n\t\t<p><label> Address Line 1 <span class=\"orang\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"address-1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"address-1\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column-half col-righ\">\n\t\t<p><label> Address Line 2<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"address-2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"address-2\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"form-row\">\n\t<div class=\"column-half\">\n\t\t<p><label> City <span class=\"orang\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-city\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-city\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column-half col-righ\">\n\t\t<p><label> State <span class=\"orang\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-state\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-state\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"form-row\">\n\t<div class=\"column-half\">\n\t\t<p><label> Zip <span class=\"orang\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-zip\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-zip\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column-half col-righ\">\n\t\t<p><label> Email Address <span class=\"orang\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"form-row\">\n\t<div class=\"column-half\">\n\t\t<p><label> Mobile Phone <span class=\"orang\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mobile-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"mobile-phone\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column-half col-righ\">\n\t\t<p><label> Work Phone<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"work-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"work-phone\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"form-row\">\n\t<div class=\"column-half\">\n\t\t<p><label> Highest Degree Completed <span class=\"orang\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"highest-degree\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"highest-degree\"><option value=\"MA\">MA<\/option><option value=\"MS\">MS<\/option><option value=\"MCMH\">MCMH<\/option><option value=\"MFT\">MFT<\/option><option value=\"PhD\">PhD<\/option><option value=\"Other\">Other<\/option><\/select><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column-half col-righ\">\n\t\t<p><label> Degree Major <span class=\"orang\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"degree-major\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"degree-major\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"form-row\" style=\"clear: both; margin-top: 1em;\">\n\t<p><label style=\"width: 91%;\"> Indicate all other degrees earned with accompanying majors<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-degree\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"other-degree\"><\/textarea><\/span> <\/label>\n\t<\/p>\n<\/div>\n<p><label> I am <span class=\"orang\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"current-license\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"current-license[]\" value=\"Currently Seeking Licensure\" \/><span class=\"wpcf7-list-item-label\">Currently Seeking Licensure<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"current-license[]\" value=\"Already Licensed\" \/><span class=\"wpcf7-list-item-label\">Already Licensed<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-license[]\" value=\"Not Licensed, but plan to\" \/><span class=\"wpcf7-list-item-label\">Not Licensed, but plan to<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Current Licenses<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pick-license\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"pick-license\"><option value=\"LAPC\">LAPC<\/option><option value=\"LPC\">LPC<\/option><option value=\"AMFT\">AMFT<\/option><option value=\"LMFT\">LMFT<\/option><option value=\"LCSW\">LCSW<\/option><option value=\"NONE\">NONE<\/option><\/select><\/span> <\/label>\n<\/p>\n<p><label> If not yet licensed but you are planning to be, indicate which of the following applies to you. Check all that apply<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"check-2\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"check-2[]\" value=\"NCE passed\" \/><span class=\"wpcf7-list-item-label\">NCE passed<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"check-2[]\" value=\"NCE to be taken\" \/><span class=\"wpcf7-list-item-label\">NCE to be taken<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"check-2[]\" value=\"NCMHCE exam passed NMHCE exam to be taken MFT exam passed\" \/><span class=\"wpcf7-list-item-label\">NCMHCE exam passed NMHCE exam to be taken MFT exam passed<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"check-2[]\" value=\"MFT exam to be taken\" \/><span class=\"wpcf7-list-item-label\">MFT exam to be taken<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"check-2[]\" value=\"LAPC \/ AMFT application sent to the board\" \/><span class=\"wpcf7-list-item-label\">LAPC \/ AMFT application sent to the board<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"check-2[]\" value=\"LAPC \/ AMFT licensure information begin collected but not sent to the board\" \/><span class=\"wpcf7-list-item-label\">LAPC \/ AMFT licensure information begin collected but not sent to the board<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<div class=\"form-row\">\n\t<div class=\"column-half\">\n\t\t<p><label> Place of Employment <span class=\"orang\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"place-employment\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"place-employment\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column-half col-righ\">\n\t\t<p><label> Address Line 1 <span class=\"orang\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"waddress-1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"waddress-1\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"form-row\">\n\t<div class=\"column-half\">\n\t\t<p><label> Place of Employment <span class=\"orang\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"place-employment\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"place-employment\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column-half col-righ\">\n\t\t<p><label> Address Line 1 <span class=\"orang\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"waddress-1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"waddress-1\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"form-row\">\n\t<div class=\"column-half\">\n\t\t<p><label> Address Line 2<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"waddress-2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"waddress-2\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column-half col-righ\">\n\t\t<p><label> City <span class=\"orang\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-wcity\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-wcity\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"form-row\">\n\t<div class=\"column-half\">\n\t\t<p><label> State <span class=\"orang\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-wstate\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-wstate\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column-half col-righ\">\n\t\t<p><label> Zip <span class=\"orang\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-wzip\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-wzip\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"form-row\" style=\"clear: both; margin-top: 1em;\">\n\t<p><label style=\"width: 91%;\"> Describe your clinical setting - including size of organization, population, typical, and daily activities<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"clinical-setting\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"clinical-setting\"><\/textarea><\/span> <\/label>\n\t<\/p>\n<\/div>\n<p><label> Attach Resume<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"resume\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file wpcf7-validates-as-required\" accept=\".pdf,.doc\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"resume\" \/><\/span> <\/label>\n<\/p>\n<div class=\"form-row\" style=\"clear: both;\">\n\t<p><label style=\"width: 91%;\"> Please describe what you are looking for within supervision relationship<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"supervision-relationship\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"supervision-relationship\"><\/textarea><\/span> <\/label>\n\t<\/p>\n<\/div>\n<p><b>By submitting this form:<\/b><br \/>\n<label> I confirm that the information provided above is true and accurate. <\/label>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner cf7sub\" type=\"submit\" value=\"Submit\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id class=\"brz-css-klRCe brz-css-uBZ9_ brz-wrapper\">\n<div class=\"brz-spacer brz-css-xDp0R brz-css-ruRZw\"><\/div>\n<\/div>\n<div id class=\"brz-css-klRCe brz-wrapper\">\n<div class=\"brz-rich-text brz-rich-text__custom brz-css-nETzh\" data-brz-custom-id=\"ulpuqhdojguattiyftcdalgatvjkreowwcgy\">\n<div data-brz-translate-text=\"1\">\n<p class=\"brz-mb-lg-0 brz-tp-paragraph brz-css-d5m4V\"><span class=\"brz-cp-color7\"> <\/span><\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/section>\n<section id=\"abfpuacrdsuxnpnbgqwhapormuwkyplaasdm\" class=\"brz-section brz-css-hqDtc\">\n<div class=\"brz-section__content brz-section--boxed brz-css-lGcvB brz-css-mLo_u\" data-brz-custom-id=\"sfubdqpktzxlcgjoxtqqvfcxnpmxzxrzkzxi\">\n<div class=\"brz-bg\">\n<div class=\"brz-bg-image\"><\/div>\n<div class=\"brz-bg-color\"><\/div>\n<\/div>\n<div class=\"brz-container brz-css-qwa2g brz-css-frsUx\">\n<div id class=\"brz-css-klRCe brz-css-vKwNv brz-wrapper\">\n<div class=\"brz-rich-text brz-rich-text__custom brz-css-nETzh\" data-brz-custom-id=\"disvblqpvzfuarizbagibtyiicvrvfckqjne\">\n<div data-brz-translate-text=\"1\">\n<p class=\"brz-text-lg-center brz-tp-abovetitle brz-css-eDSxA\"><span class=\"brz-cp-color3\">WHAT&#8217;S NEXT?<\/span><\/p>\n<\/div>\n<\/div>\n<\/div>\n<div id class=\"brz-css-klRCe brz-css-vctU8 brz-wrapper\">\n<div class=\"brz-rich-text brz-rich-text__custom brz-css-nETzh\" data-brz-custom-id=\"bwjppemjhizoclmmnetejqprrxhdxwpuzmsf\">\n<div data-brz-translate-text=\"1\">\n<h2 class=\"brz-text-lg-center brz-lh-lg-1_4 brz-lh-sm-im-undefined brz-lh-xs-im-1_3 brz-ls-lg-m_1 brz-ls-sm-im-undefined brz-ls-xs-im-m_0_5 brz-ff-playfair_display brz-fw-lg-700 brz-fw-sm-im-undefined brz-fw-xs-im-700 brz-fs-lg-48 brz-fs-sm-im-26 brz-fs-xs-im-30 brz-css-qFnX_\"><span class=\"brz-cp-color8\">After Sign-up Form Submission<\/span><\/h2>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"brz-wrapper-clone brz-css-x_5ga\">\n<div class=\"brz-d-xs-flex brz-flex-xs-wrap brz-css-s1e42\" data-brz-custom-id>\n<div class=\"brz-wrapper-clone__item\" id=\"hhgcsyevsngzctowmzpbbkyishjakuxnknai\">\n<div class=\"brz-icon__container\" data-brz-custom-id=\"hhgcsyevsngzctowmzpbbkyishjakuxnknai\"><span class=\"brz-icon brz-span brz-css-ss3_n brz-css-vUxUT\"><\/span><\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id class=\"brz-css-klRCe brz-wrapper\">\n<div class=\"brz-rich-text brz-rich-text__custom brz-css-nETzh\" data-brz-custom-id=\"ouhjlwbieakwooqxxwgpbinfpzhvcstszeus\">\n<div data-brz-translate-text=\"1\">\n<p class=\"brz-text-lg-center brz-tp-paragraph brz-css-eXiwE\"><span class=\"brz-cp-color6\"> <\/span><span style=\"background-color: transparent\" class=\"brz-cp-color6\">Please click the link below to download a folder with files you will need.<\/span><span class=\"brz-cp-color6\"> <\/span><\/p>\n<\/div>\n<\/div>\n<\/div>\n<div id class=\"brz-css-klRCe brz-css-uBZ9_ brz-wrapper\">\n<div class=\"brz-spacer brz-css-xDp0R brz-css-tJ1A8\"><\/div>\n<\/div>\n<div class=\"brz-wrapper-clone brz-css-x_5ga\">\n<div class=\"brz-d-xs-flex brz-flex-xs-wrap brz-css-s1e42\" data-brz-custom-id>\n<div class=\"brz-wrapper-clone__item\" id=\"xqdmsexmzreltmhxqzkmhobmyeshwrthmtet\"><a class=\"brz-a brz-btn brz-css-cGgPT brz-css-hekKm\" href=\"https:\/\/drsonjasutherland.com\/wp-content\/uploads\/2019\/11\/DSS_Supervision-forms_2019-1.zip\" target=\"_blank\" rel=\"noopener\" data-brz-link-type=\"upload\" data-brz-custom-id=\"xqdmsexmzreltmhxqzkmhobmyeshwrthmtet\"><span data-brz-translate-text=\"1\" class=\"brz-span brz-text__editor\">DOWNLOAD FORMS HERE<\/span><\/a><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/section>\n<\/div>\n<p>    <!-- version:1710202573 --><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Individual Supervision Indicate your choice of supervision services from the options below. Supervision Options: Individual Supervision Triadic Supervision Group Supervision Dr. Sonja Sutherland \/ Counselors Corner \/ Supervision Services \/ Individual Supervision WHAT&#8217;S NEXT? After Sign-up Form Submission Please click the link below to download a folder with files you will need. DOWNLOAD FORMS HERE<\/p>\n","protected":false},"author":9,"featured_media":0,"parent":3876,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"visual-builder-template.php","meta":{"footnotes":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.2 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Clinical Supervision Form &#8211; Individual - Dr. Sonja Sutherland<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/drsonjasutherland.com\/counselors-corner\/supervision-services\/clinical-supervision-form-individual\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Clinical Supervision Form &#8211; Individual - Dr. Sonja Sutherland\" \/>\n<meta property=\"og:description\" content=\"Individual Supervision Indicate your choice of supervision services from the options below. Supervision Options: Individual Supervision Triadic Supervision Group Supervision Dr. Sonja Sutherland \/ Counselors Corner \/ Supervision Services \/ Individual Supervision WHAT&#8217;S NEXT? After Sign-up Form Submission Please click the link below to download a folder with files you will need. 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Supervision Options: Individual Supervision Triadic Supervision Group Supervision Dr. Sonja Sutherland \/ Counselors Corner \/ Supervision Services \/ Individual Supervision WHAT&#8217;S NEXT? After Sign-up Form Submission Please click the link below to download a folder with files you will need. 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