Supervisor Waitlist Application

Step 1: Professional Information

Full Name *

Email Address *

Phone Number *

Professional Title / Credentials *

Profession *

Please specify your profession

Years of Professional Experience *

Practice City *

Practice State *

What are the requirements in your profession for supervising an emerging professional? *

Step 2: Practice Details

What type of setting do you work in? *

Please describe the type of patients seen and setting model

Are you currently employed or self-employed? *

Are there any employer or facility requirements that must be met before an emerging professional can be hosted? *

e.g., background checks, affiliation agreements

Are you permitted to host an emerging professional through your current role or setting? *

Step 3: Supervision Preferences

Which types of emerging professionals are you open to supervising? (Select all that apply) *

Undergraduates in pre-clinical training

Master's students

Doctoral students

Post-graduate professionals completing required hours for licensure

International professionals seeking credentialing

Other

Are you open to supervising emerging professionals remotely? *

telehealth, report reviews, or observation-based

How many emerging professionals could you supervise at one time? *

What is your typical availability for supervision per week? *

Are you multilingual? *

Step 4: Compensation & Review

Are you interested in charging a fee for externship supervision? *

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Review Your Information

Please review your information above and click submit when you're ready to join our supervisor network.

✓ Professional credentials and experience
✓ Practice setting and employment details