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Name
*
First
Last
Email
*
Phone Number
*
Is it okay to text this number (i.e., session or appointment reminders)?
*
Yes
No
Supervision Type
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Individual Supervision
Dyadic Supervision
Group Supervision
If you are registering for dyadic or group supervision, are you applying with another individual or group?
Yes
No
If yes, please list the name(s) of the individual(s) who will be in your dyad or group:
Name of your Primary Practice
Practice Location
Practice Phone Number
Practice Website
What therapeutic modalities do you use in your work?
*
What age ranges do you work with?
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Children (5-9)*
Adolescents (10-13)*
Adolescents (14-17)*
Young Adults
Adults
Older Adults
Seniors
*If you have competency to work with children and adolescents, please tell us about your training/certifications:
Type of Therapy you Provide
*
Individual
Couples*
Family*
Groups
*If you have competency to work with couples or families, please tell us about your training/certifications:
How long have you been practicing for (post-graduate)
*
newly graduated/less than one year
1-4 years
5-10 years
11-15 years
more than 15 years
License Number
*
Date of Registration
*
Credentials
*
Registered Psychotherapist (w/ Independent Practice)
Registered Psychotherapist (w/o Independent Practice)
Registered Psychotherapist (Qualifying)
Registered Social Worker
If you have had any complaints filed with a governing body, such as the CRPO or OCSWSSW, or have any criminal charges laid against you, please provide the details here:
*
I certify that I am a member in good standing with the CRPO or OCSWSSW:
*
Yes
Are you interested in other Our Practice Services? (e.g., Our Community Rooms)
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