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Clinical Supervision
Clinical Supervision
Clinical Supervision is provided for Texas Licensed Professional Counselor Associates. Malpractice insurance is required. If you are new, please upload your resume and schedule a free interview session. Please review the contract and supervisory agreement in advance. If you have been interviewed and completed the contract, supervisory agreement form, and the fee agreement, you may schedule your session.
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Supervision Contract
Supervision Fee Agreement
Link to LPC (Board) Supervisory Agreement Form
CLINICAL SUPERVISION
1
Booking Details
2
Services
3
Term & Conditions
4
Term & Conditions
5
Term & Conditions
6
Select Date
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Payment Details
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9
10
Name
First
Last
Email
Phone
Services
Expert Testimony
Therapy
Clinical Supervision
Consultation
THERAPY INTAKE
Name
Date of birth
MM slash DD slash YYYY
Age
Phone
Email
Is it OK to leave a message at this number?
Yes
No
Is it OK to send you an email?
Yes
No
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Employer:
School:
Sex/Gender
Male
Female
Transgender Male
Transgender Female
Genderqueer
Choose not to disclose
Current relationship status (please “X” one)
Single
Married
Partnered/Committed relationship
Separated
Divorced
Remarried
Widowed
Sexual Orientation
Straight/heterosexual
Lesbian/homosexual
Gay/homosexual
Bisexual
Something else
Don’t know
Choose not to disclose
Pronouns
He/him
She/her
They/them
Other: please specify
Name of Significant other:
Age:
Occupation:
Years Married:
Previous marriages:
yes
No
List
# of years married:
years of divorce:
reason for divorce:
Add
Remove
Who currently lives in your household?
Please list age and gender of your children:
List
Gender
Age
Relationship
Add
Remove
Are there any relationships that you are concerned about?
Abuse History:
Are you currently in an abusive relationship?
Yes
No
If “Yes”, check the types of abuse that apply to this relationship:
Emotional
Sexual
Financial
Spiritual
Verbal
Physical
How often does this occur?
Daily
Weekly
other
Other
Have you had past relationships that were abusive?
Yes
No
If “Yes”, please describe:
Were you ever sexually violated/assaulted as a child (0-18 years)?
Yes
No
List
If “Yes”, how old were you?
by whom?
Relationship
Add
Remove
Have you ever been sexually assaulted or raped as an adult?
Yes
No
List
“Yes”, when?
by whom?
Relationship
Add
Remove
Were charges filed?
Yes
No
Did you receive counseling?
Yes
No
Therapy History:
Are you currently receiving therapy with anyone?
Yes
No
Have you ever received any type of counseling services before today?
Yes
No
When?
Add
Remove
From whom?
Add
Remove
For what?
Add
Remove
Medical History:
Do you have any current medical conditions (particularly seizures, diabetes, and sickle cell)?
Please list any mental health diagnoses received from a mental health or medical professional:
What treatments have you tried for these medical and mental health diagnoses?
Have you ever been hospitalized for medical reasons other than childbirth?
Yes
No
for what reasons?
Have you ever been hospitalized for mental health reasons?
Yes
No
Is there a history of drug or alcohol usage?
Yes
No
drug
Drug/Alcohol Type
Frequency
Add
Remove
Is there a family history of drug or alcohol usage?
Yes
No
drug
Relationship
Describe
Add
Remove
Are you currently taking any prescription medications? Over the counter medications?
Yes
No
Medication
Medication
Dosage
Prescribing Doctor
Add
Remove
Have you ever suffered a head injury? (Car accidents, sports, violence, etc.)
Have you ever experienced any unusual states of consciousness like hallucinations, loss of time, long periods of confusion, out of body, etc.?
Symptom History:
Name
Phone Number
Physical Address
Email Address
What symptoms/problems are you hoping to improve?
When did these symptoms/problems first become noticeable?
What have been the major negative consequences of these symptoms/problems?
Please list your three primary goals for therapy.
1.
2.
3.
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Consent for Telehealth
Emergency Contact
Fee Agreement
Informed Consent General
Practice Policies
Assessments
Cross Cutting Symptom Measure - Adult
Level 2 Substance Use - Adult
Severity Measure for Generalized Anxiety Disorder - Adult
Severity Measure of Depression - Adult
Severity of Posttraumatic Stress Symptoms - Adult
WHODAS 2.0 36-item
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Schedule
Interview (1 hr)
Supervision (1 hr)
Date
(Required)
MM slash DD slash YYYY
Time
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Payment
$0.00
Name
First
Last
Phone
Email
Your Role (CHECK ONE):
Prosecutor
Defense Attorney
Plaintiff Attorney
Respondent Attorney
Client
Type of Case (Check One):
Divorce/Custody
Protective Order
Criminal
Other (Please specify)
Other
Court Date
Date
MM slash DD slash YYYY
_____________ Not yet scheduled
Approximate time needed for consultation
Hours
:
Minutes
AM
PM
AM/PM
Brief Overview of Case
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Max. file size: 1 GB.
Name
First
Last
Phone
Email
Your Role (CHECK ONE):
Prosecutor
Defense Attorney
Plaintiff Attorney
Respondent Attorney
Client
Type of Case (Check One):
Divorce/Custody
Protective Order
Criminal
Other (Please specify)
Other
Court Date
Date
MM slash DD slash YYYY
_____________ Not yet scheduled
Approximate time needed for consultation
Hours
:
Minutes
AM
PM
AM/PM
Brief Overview of Case
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Drop files here or
Select files
Max. file size: 1 GB.
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Supervision Contract
Fee Agreement for Supervision wRight Insight
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Max. file size: 1 GB.
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Registration for General Public Course
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Select Date
October 2026
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October 8, 2026
9:00 AM - 9:45 AM
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October 12, 2026
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October 13, 2026
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October 14, 2026
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October 15, 2026
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October 19, 2026
9:00 AM - 9:45 AM
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October 20, 2026
9:00 AM - 9:45 AM
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October 21, 2026
9:00 AM - 9:45 AM
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October 22, 2026
9:00 AM - 9:45 AM
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October 26, 2026
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October 27, 2026
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October 28, 2026
9:00 AM - 9:45 AM
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Time Duration
15 Minutes
Time Duration
45 Minutes
Payments
$0.00
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