MENTORSHIP APPLICATION FORM

Name*

Email*

Phone Number

Location

Institution and Graduation Date

If you are seeking supervision hours as an LMSW, please note where you received your MSW (or other licensure program) and your date of graduation. (Pending dates are also fine.)

Type of License & License Number*

Please note your LMSW, LCSW, or other type of practitioner license number, and state and date of licensure. If you are not yet licensed, but have graduated/are graduating soon and plan to take the LMSW or other type of licensure exam soon, please note your exam date. If we meet for an interview, I will ask you to provide verification of the scheduled exam. If you are a 2nd-year student, please write in "N/A."

Related Experience*

Please note any internships, practicums, volunteer or other work you've done related to the populations listed above.

Personal and Professional Goals*

Please describe how this position will fit in with your current life and schedule, and support your goals.

Statement of Interest*

Please describe how you would be a good fit for working with me and the populations my practice serves.

Availability*

Please list your availability to see clients, noting any preferred days and times.

Example bio*

Please write an example of a public-facing bio (~100 to 150 words), i.e., how you would describe yourself and your therapeutic approach to the public.

Upload CV/Resume

PDF/ODT/DOC/PPT files up to 20 MB.

Please provide name and contact info for two professional references (supervisor, employer, professor, and/or advisor, if possible):

I am interested in (choose all that apply):

A supervised fee-for-service position

Case consultation/drop-in supervision

AASECT continuing education credits

AASECT CST supervision hours

Graduate internship

Not sure