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Application for Supervision

Welcome friend! Let’s Find Out if We're a Good Fit for Working Together

-Thanks for your interest. This short form helps us both make sure we’re a good match to work together for your supervision and professional development.

-I work best with counselors who are grounded in classic reflective listening skills, who value presence-in-the-room, and are committed to lifelong learning.

-If you sign up for Supervision with me, I'll be in your corner 100% of the way.
-And the process for onboarding with me is simple and straightforward.

Your full name:

Your state of residence:

Your email address (no spam):

Your phone (no spam):

How did you hear about Katharine?

How did you hear about Katharine?
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Are you currently licensed as an LPC in Idaho?

Are you currently licensed as an LPC in Idaho?
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If so, Idaho LPC license number:

Primary work setting:

Primary population you work with:

You understand that Idaho requires supervised clinical experience and supervision hours to qualify for LCPC licensure. You understand that YOU are responsible for tracking your clinical hours and ensuring they meet Idaho Board requirements:

You understand that Idaho requires supervised clinical experience and supervision hours to qualify for LCPC licensure. You understand that YOU are responsible for tracking your clinical hours and ensuring they meet Idaho Board requirements:
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You understand that supervision is a paid professional service and is not covered by insurance. You also understand that supervision includes case review, documentation review, ethics discussion, and evaluation of clinical competency:

You understand that supervision is a paid professional service and is not covered by insurance. You also understand that supervision includes case review, documentation review, ethics discussion, and evaluation of clinical competency:
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B

You understand that supervision is not therapy, business coaching, or crisis coverage, but structured clinical oversight focused on competency, ethics, and case consultation:

You understand that supervision is not therapy, business coaching, or crisis coverage, but structured clinical oversight focused on competency, ethics, and case consultation:
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B

Katharine's window for meetings is Tues-Fri, 9am MST to 3pm MST. Can you make this window work to meet for 1 hr for every 20 hours of direct client contact you accrue?

Katharine's window for meetings is Tues-Fri, 9am MST to 3pm MST. Can you make this window work to meet for 1 hr for every 20 hours of direct client contact you accrue?
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B

Please indicate the ideal day and time for your meetings with Katharine for Supervision (within Tues-Fri, 9am-3pm MST:)

What counseling program did you complete or are you currently enrolled in?

What clinical theories or approaches do you use most often?

Approximately how many post-master’s supervised clinical hours have you already completed?

Approximately how many direct client hours have you completed?

Are you currently receiving supervision elsewhere? If so, where and with whom?

How soon are you hoping to begin supervision with Katharine?

What do you think are your strongest clinical skills right now?

What types of clinical cases challenge you the most?

You understand that your supervisor has a gatekeeping role and will not sign off on hours unless competencies are demonstrated.

You understand that your supervisor has a gatekeeping role and will not sign off on hours unless competencies are demonstrated.
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You understand that supervision may include direct feedback, challenge, and evaluation of readiness for independent LCPC practice. You are open to examining countertransference, blind spots, and personal patterns that affect your clinical work:

You understand that supervision may include direct feedback, challenge, and evaluation of readiness for independent LCPC practice. You are open to examining countertransference, blind spots, and personal patterns that affect your clinical work:
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B

Describe a recent ethical dilemma or clinical challenge you faced.

What do you want most from a supervisor?

You understand Katharine's rate for supervision is $350 per month, paid monthly via PayPal subscription:

You understand Katharine's rate for supervision is $350 per month, paid monthly via PayPal subscription:
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