Antioch University New England

Applied Psychology - Clinical Mental Health Counseling Program
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Field Site Supervisor Information Form - Clinical Mental Health Program - Applied Psychology - Antioch University New England

Field Site Supervisor Information Form

In order to better serve our students we make every effort to keep our practicum and internship file current. This includes information regarding on-site supervisors. Please assist us in this effort by completing the following form and updating it as needed. Thank you.

* required fields

Full Name*

First                                           Last

Agency Name *

Agency Address*


City                          State                                  Zip

Current Position *

     

Years at the Agency *

Email*

(e.g. username@hotmail.com)

     

Phone *

(e.g. 603.358.2000)

Degree*

     

Degree Field *

Licensure Type
None
LADAC
LCMHC
LICSW
LNMFT
Licensed Psychologist
Other:

Years of Practice*

Years of Supervisory Experience *

Years of Field Site Supervisor for Antioch University New England Students

Please check the Professional Organizations to which you belong.
American Association of Counseling (ACA)
American Mental Health Counselor Association (AMHCA)
Association for Counselor Education and Supervision (ACES)
National Board for Certified Counselors (NBCC)
North Atlantic Region ACES (NAACES)
Approved Clinical Supervisor (ACS)
Association of Marriage and Family Therapists
Other:

Please list any specialized training you have received in the area of supervision

Please list any Certifications you currently hold


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Last Updated: 4/21/08