Supervision Interest Form

Please complete this form if you are interested in EFT supervision or supervision for an LPC-Associate in Texas.

Please correct the errors described below.

Emergency Assistance

You are having thoughts of suicide or of harming yourself or someone else, please do not submit this form. Instead, get immediate help by calling 911 or the Suicide Hotline at 800-273-8255

First Name

Last Name

Phone Number

Location: Country, State or Region, City

License Type and Number (if applicable)

I am interested in: Check all that apply

EFT Individual Supervision

EFT Group Supervision

Supervision for Licensure

Case Consultation

Other

For licensure supervision: please list your school, degree, and anticipated graduation or licensure date.

For EFT Supervision: please check the trainings / experiences you have already completed.

EFT Externship

Core Skills

Previous Individual Supervision

Previous Group Supervision

Other

What questions do you have? What would you like me to know?

Please note that if you are requesting an appointment or share personal health information, your response email will be encrypted. That keeps your information safer but will require that you create a passcode to open it.

Your information will be encrypted.

Emergency Assistance

You are having thoughts of suicide or of harming yourself or someone else, please do not submit this form. Instead, get immediate help by calling 911 or the Suicide Hotline at 800-273-8255

Le Shepard, LPC - Supervisor

Owner / Therapist, 1000 Hills Counseling

940-202-9597
1000HillsCounseling.com

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