READY TO START COUNSELOR TELE-SUPERVISION?

First Name (required)

Last Name *

Email Address *

Telephone Number *

Comments / Questions About Supervision

Masters Degree Graduation Date *

Name of Graduate School Where Degree Completed *

Degree Discipline *

Days You Are NOT Available To Attend Tele-Supervision *
Monday Before 5pmTuesday Before 5pmTuesday After 6:30pmWednesday Before 5pmWednesday After 6:30pm

Name of Employer/ Contract Company where you will be working while receiving supervision *

Who is your Administrative Supervisor/Director at your place of employment/contract company (include any credentials after their name)?*

Employer / Contract Company Home Office City Location *
AbbevilleAcworthAdairsvilleAdelAdrianAileyAlamoAlapahaAlbanyAldoraAllenhurstAllentownAlmaAlpharettaAlstonAltoAmbroseAmericusAndersonvilleArabiAragonArcadeArgyleArlingtonArnoldsvilleAshburnAthens-Clarke CountyAtlantaAttapulgusAuburnAugusta-Richmond County (balance)AustellAvalonAveraAvondale EstatesBacontonBainbridgeBaldwinBall GroundBarnesvilleBartowBarwickBaxleyBellvilleBelvedere ParkBerkeley LakeBerlinBethlehemBetweenBibb CityBishopBlackshearBlacksvilleBlairsvilleBlakelyBloomingdaleBlue RidgeBlufftonBlytheBogartBonanzaBostonBostwickBowdonBowersvilleBowmanBraseltonBraswellBremenBrinsonBronwoodBrookletBrooksBroxtonBrunswickBuchananBuckheadBuena VistaBufordButlerByromvilleByronCadwellCairoCalhounCamakCamillaCandler-McAfeeCanonCantonCarlCarltonCarnesvilleCarrolltonCartersvilleCave SpringCecilCedartownCentervilleCentralhatcheeChambleeChatsworthChattanooga ValleyChaunceyChesterChickamaugaClarkesvilleClarkstonClaxtonClaytonClermontClevelandClimaxCobbtownCochranCohuttaColbertColemanCollege ParkCollinsColquittColumbus cityComerCommerceConcordConleyConyersCoolidgeCordeleCorinthCorneliaCountry Club EstatesCovingtonCrawfordCrawfordvilleCullodenCummingCussetaCuthbertDaculaDahlonegaDaisyDallasDaltonDamascusDanielsvilleDanvilleDarienDasherDavisboroDawsonDawsonvilleDearingDecaturDeenwoodDeepstepDemorestDentonDe SotoDexterDillardDock JunctionDoerunDonalsonvilleDoolingDoravilleDouglasDouglasvilleDruid HillsDublinDudleyDuluthDunwoodyDu PontEast DublinEast EllijayEast GriffinEastmanEast NewnanEast PointEatontonEdge HillEdisonElbertonEllavilleEllentonEllijayEmersonEnigmaEphesusEtonEuharleeEvansExperimentFairburnFairmountFair OaksFairviewFargoFayettevilleFitzgeraldFlemingtonFlovillaFlowery BranchFolkstonForest ParkForsythFort Benning SouthFort GainesFort OglethorpeFort StewartFort ValleyFranklinFranklin SpringsFunstonGainesvilleGarden CityGarfieldGayGenevaGeorgetownGeorgetownGibsonGillsvilleGirardGlennvilleGlenwoodGood HopeGordonGrahamGrantvilleGrayGraysonGreensboroGreenvilleGresham ParkGriffinGrovetownGumbranchGumlogGuytonHaganHahiraHamiltonHamptonHannahs MillHapevilleHaralsonHarlemHarrisonHartwellHawkinsvilleHazlehurstHelenHelenaHephzibahHiawasseeHiggstonHilltopHiltoniaHinesvilleHiramHobokenHogansvilleHolly SpringsHomelandHomerHomervilleHoschtonHullIdealIlaIndian SpringsIron CityIrondaleIrwintonIsle of HopeIveyJacksonJacksonvilleJakinJasperJeffersonJeffersonvilleJenkinsburgJerseyJesupJonesboroJunction CityKennesawKeysvilleKings Bay BaseKingslandKingstonKiteLa FayetteLaGrangeLake CityLakelandLake ParkLakeviewLakeview EstatesLavoniaLawrencevilleLearyLeesburgLenoxLeslieLexingtonLilburnLillyLincoln ParkLincolntonLindaleLithia SpringsLithoniaLocust GroveLoganvilleLone OakLookout MountainLouisvilleLovejoyLudowiciLulaLumber CityLumpkinLuthersvilleLyerlyLyonsMabletonMcCaysvilleMcDonoughMcIntyreMaconMcRaeMadisonManassasManchesterMansfieldMariettaMarshallvilleMartinMartinezMaxeysMaysvilleMeansvilleMeigsMenloMetterMidvilleMidwayMidway-HardwickMilanMilledgevilleMillenMilnerMitchellMolenaMonroeMontezumaMontgomeryMonticelloMontroseMoody AFBMorelandMorganMorgantonMorrowMorvenMoultrieMountain CityMountain ParkMountain ParkMount AiryMount VernonMount ZionNahuntaNashvilleNelsonNewbornNewingtonNewnanNewtonNichollsNicholsonNorcrossNorman ParkNorth AtlantaNorth DecaturNorth Druid HillsNorth High ShoalsNorwoodNunezOak ParkOakwoodOchlockneeOcillaOconeeOdumOffermanOglethorpeOliverOmegaOrchard HillOtherOxfordPalmettoPanthersvilleParrottPattersonPavoPaynePeachtree CityPearsonPelhamPembrokePendergrassPerryPhillipsburgPinehurstPine LakePine MountainPineviewPittsPlainsPlainvillePoolerPortalPorterdalePort WentworthPoulanPowder SpringsPrestonPulaskiPutneyQuitmanRangerRaoulRay CityRayleRebeccaRedanReed CreekRegisterReidsvilleRemertonRentzResacaRest HavenReynoldsRhineRiceboroRichlandRichmond HillRiddlevilleRinconRinggoldRiverdaleRiversideRobertaRobins AFBRochelleRockmartRocky FordRomeRoopvilleRossvilleRoswellRoystonRutledgeSt. MarysSt. SimonsSale CitySalemSandersvilleSandy SpringsSanta ClausSardisSasserSavannahScotlandScottdaleScrevenSenoiaShady DaleShannonSharonSharpsburgShellmanShilohSiloamSkidaway IslandSky ValleySmithvilleSmyrnaSnellvilleSocial CircleSopertonSparksSpartaSpringfieldStapletonStatesboroStathamStillmoreStockbridgeStone MountainSugar HillSummertownSummervilleSumnerSunny SideSunnysideSunset VillageSurrencySuwaneeSwainsboroSycamoreSylvaniaSylvesterTalbottonTalking RockTallapoosaTallulah FallsTalmoTarrytown villageTaylorsvilleTempleTennilleThomastonThomasvilleThomsonThunderboltTiftonTigerTignallToccoaToomsboroTrentonTrionTuckerTunnel HillTurinTwin CityTybee IslandTyroneTy TyUnadillaUnion CityUnion PointUnionvilleUvaldaValdostaVarnellVernonburgVidaliaVidetteViennaVilla RicaViningsWacoWadleyWaleskaWalnut GroveWalthourvilleWarm SpringsWarner RobinsWarrentonWarwickWashingtonWatkinsvilleWaverly HallWaycrossWaynesboroWestonWest PointWhighamWhiteWhitemarsh IslandWhite PlainsWhitesburgWillacoocheeWilliamsonWilmington IslandWinderWintervilleWoodbineWoodburyWoodlandWoodstockWoodvilleWoolseyWrensWrightsvilleYatesvilleYoung HarrisZebulon

Your Position Title *

Brief Position Description (Duties) *

Describe what you are ideally looking for in a clinical supervisor, and explain positive/negative takeaways from any past supervisee experience *

Have your previously applied for LPC licensure (not LAPC/APC), but were denied, and need to resolve deficiencies noted by the State Composite Board? *
YesNoIt's Complicated

What do you feel/think are your greatest needs for developing professionally as a counselor?*

Do you have high-speed internet and an up-to-date smart-device to be able to participate in tele-supervision?*
YesNoMaybeOnce I know what is needed, I will have it before supervision begins

Please attach your Resume or Clinical Vitae*

How did you learn about tele-supervision provided by Elana of TherapyStudio.Live? *
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