External Supervision for Provisional Hours

If you run into any complications with this form, please reach out to our Clinic Manager, Rhian Knowles

hello@squarepegpsychology.ca

Date

Name

Phone number

Email address

Hello and thank you for your interest in external supervision of your Provisional Psychologist hours with Susan Larcombe, Registered Psychologist (AB 3836).

Please take some time to complete the form below in order to help determine whether we would be a good fit for supervision. An appropriate and supportive match can make such a difference in your learning and development.

I have reviewed the Supervision page on the Square Peg Psychology website and am aware of Susan's current availability for external supervision of Provisionals. I have completed the following stage/s in my application for a Provisional Psychologist license:

Masters Degree conferred

Credentials approved by the College of Alberta Psychologists

Work site confirmed

I am seeking the following from Susan Larcombe, RPsych:

Primary Supervison

Secondary Supervision

Unsure

Please upload a copy of your CV. Please ensure it demonstrates familiarity with the client demographics you would be likely to encounter as a practicum student at Square Peg Psychology.

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Please upload your cover letter here. Please ensure it is tailored to a practicum placement at this practice and is not a generic cover letter detailing your program requirements.

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I confirm that I have reviewed the Square Peg Psychology website. I confirm that my interests and grounding theories or theoretical models are an appropriate fit for supervision by Susan Larcombe, RPsych.

What theoretical models do you use (or have interest in using) with adults, to conceptualize their case and draw interventions from?

I understand that the clients I work during my Provisional hours will set the tone for the early stages of my career as a mental health professional and that I should therefore seek out a clinical setting where I will gain experience working with the types of clients I am passionate about.

If you have a work site confirmed, please list it here. Please respond to the following questions according to the clients you will see at this work site.

What client ages do you want to work with? Please note I cannot supervise clients who present whose ages fall outside of my scope of competence.

Children

Adolescents

Adults

Which of the following groups of individuals do you have personal and/or professional experience with, in a supportive capacity?

Neurodiverse individuals

2SLGBTQIA+ folks

BIPOC individuals

Differently-abled individuals

Consensually Non-Monogamous individuals

Folks from a different (or non-)religious background to how I was raised

Please provide context for your answers above, regarding diversity.

What client issues do you hope to work with?

Please note I cannot supervise clients who present with issues outside of my scope of competence.

Please outline any trainings you have obtained outside of school specific to client-work? What trainings do you plan to take during your Provisional hours?

I understand that it is unethical as well as unhelpful to my learning to misrepresent my educational goals for my Provisional hours.

Please tell me about your Practicum experience/s, with as much detail as possible regarding the setting and the types of client work you engaged in.

What would you most hope to learn from me as your supervisor?

What aspects of clinical work do you enjoy the most? What aspects do you find challenging?

What are some traits that you possess that would be an asset to a collaborative supervisor/ supervisee relationship? What do you need from a supervisor to feel supported on your practicum journey?

What would you identify as an area professionally in which you need to grow? How do you plan on addressing this challenge?

Can you give me an example of how you dealt with conflict in a professional setting? Is there anything you would have changed about how you handled the situation?

Thank you so much for the time and reflection you have given to completing this screener.

We will be in touch within 14 business days to schedule an interview if I believe this would be a good fit.

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