Email*
Your name*
Phone number*

Mental Health Discipline*LCSWLPCAddictions CounselorOther
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License # and State of Licensure*

How many years have you been supervising?*0-23-56-1011+Other
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In what context do you supervise (check all that apply)?*agencyprivate practiceindividualgroupOther
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Please select the workshop(s) you are registering for:201: Creating the Road Map for Effective Clinical Supervision202: Settling Into Your Supervisory Style203: Sticky Situations and Satisfying Solutions

Please list any specific questions you have for the workshop:

How did you hear about these trainings?*Facebook PostEmail from Four Corners CounselingNASW ColoradoNASW NationalFriend/ColleagueLinkedInOther
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COMMUNICATION:Please DO NOT email me.
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CONSENT TO RECORD*Yes - I give my consent to recordNo - I DO NOT consent to record

ACCESSIBILITY: Do you need closed captioning or other accommodations?*YesNoOther
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GRIEVANCE POLICY*I have read and understand the Grievance Policy

PROFESSIONAL DEVELOPMENT/CONTINUING EDUCATION INFORMATION*I have read and understand the Continuing Education/Professional Development Information

PAYMENT*Payment has been made via Venmo to @fourcornerscounseling or Paypal (paypal.me/4cornerscounseling)Payment has been made by credit card (through PayPal)A check is in the mailOther
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