Clinical Supervision Request Form

Note that for licensure, 50% of clinical hours must be supervised by a professional who has the license that is sought by the supervisee (LMFT [AAMFT-approved supervisor], LCSW, LPC). For all clinical hours to count towards licensure, one hour/week of supervision is required for every 10 clinical hours/week. To count clinical hours in excess of 10/week, two weekly hours of supervision are required. Please inform CFR of your desired license, and of the number of clinical hours/week for which you desire supervision, so that CFR can work with you to assure that you will be able to count all of your clinical hours towards licensure.

Name*

First Last

Intended License or Certification*

LMFT
LPC
LCSW
AASECT-certification as a Sex Therapist

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Supervision Hours*

1 hour/week
2 hours/week

What date would you like to start?*

Supervision Type*

Individual
Group

Supervisor Requested*

Location Requested*

University City
Center City
Blue Bell
Bryn Mawr
Paoli
Voorhees
Wynnewood
Online

Are you currently seeing clients outside of CFR?*

Yes
No

If yes, where?*

Private Practice
Mental Health Agency
Religious Institution

Please describe your prior supervised counseling experience.

Number of years of supervised counseling experience

Educational Background

Psychology
Marriage and Family Therapy
Social Work
Counseling Education
Professional Counseling
Theology

Please upload your CV or resume*

Drop files here or

Max. file size: 50 MB.

How did you hear about us?*

Please check all that apply.

I am a CFR staff member, student, or alumni
I've attended continuing education offerings at CFR before
I receive CFR emails
Social Media
Web Search
CFR staff member, student, or alumni referred me
Colleague or word of mouth
Other

Would you like to sign up for our emails with more professional development news and opportunities?*

Yes
No

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Clinical Supervision Request Form

Clinical Supervision Request Form