Name*

First Last

Email (you will receive a confirmation email using this entry)*

Agency/Organization*

Cell Phone (emergencies only)*

Are you a Licensed Social Worker or Licensed Professional Counselor?*

License Number (required for continuing education)*

What is your level of endorsement, if applicable?*

Please indicate your discipline*

How many years have you been supervising IMH clinicians?*

How many people do you supervise in an IMH setting?*

Select ALL of the training dates you will be attending for the supervisor series*

What are you hoping to gain from this training?

What questions do you have for the trainer(s)? These will be given to the trainers before the training day.

ECLS.2021.5.6.Supervisor Series

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