Clinical Supervisee – Information for Placement Clinical Trainee/Associate Information Trainee/Associate Name * Trainee/Associate Name First Name First Name Last Name Last Name County of Residence * Alameda CountyAlpine CountyAmador CountyButte CountyCalaveras CountyColusa CountyContra Costa CountyDel Norte CountyEl Dorado CountyFresno CountyGlenn CountyHumboldt CountyImperial CountyInyo CountyKern CountyKings CountyLake CountyLassen CountyLos Angeles CountyMadera CountyMarin CountyMariposa CountyMendocino CountyMerced CountyModoc CountyMono CountyMonterey CountyNapa CountyNevada CountyOrange CountyPlacer CountyPlumas CountyRiverside CountySacramento CountySan Benito CountySan Bernardino CountySan Diego CountySan Francisco CountySan Joaquin CountySan Luis Obispo CountySan Mateo CountySanta Barbara CountySanta Clara CountySanta Cruz CountyShasta CountySierra CountySiskiyou CountySolano CountySonoma CountyStanislaus CountySutter CountyTehama CountyTrinity CountyTulare CountyTuolumne CountyVentura CountyYolo CountyYuba County Home Address * Home Address Home Address Home Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Mailing Address (if different) Mailing Address (if different) Mailing Address (if different) Mailing Address (if different) City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email * Phone * Emergency Contact * Emergency Contact Phone * Relationship to Emergency Contact * Placement Start Date * Anticipated or Requested Placement End Date * Resonant Counseling Supervisor Name * Lisa Wenninger, LPCC 14315 Name of Graduate Program * City and State of Graduate Program * Graduation Month and Year * Current progress in training: * Practicum Student Internship Student Post-Grad Associate Program Placement Contact Name * Program Placement Contact Email * Program Placement Contact Phone * Program Training Director Name * Program Training Director Email * Program Training Director Phone * License(s) Being Pursued * Licensed Professional Clinical Counselor Licensed Marriage and Family Therapist Licensed Clinical Social Worker OtherOther State(s) Seeking Licensure * Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands of the U.S. Virginia Washington West Virginia Wisconsin Wyoming Proof of Professional Liability Insurance * Drop a file here or click to upload Choose File Maximum file size: 52.43MB PDF only. Have you ever been convicted of a misdemeanor or felony? If so please describe, including relevant dates and current status. * Answer “NO” if: (1) you have never been convicted of a misdemeanor or felony; (2) the misdemeanor or felony was sealed, dismissed, expunged, or reversed on appeal; (3) you withdrew your plea after completing a court program and were not convicted of a misdemeanor or felony. Preferred Work Hours * Weekday mornings Weekday afternoons Weekday evenings Saturdays Sundays We will use this for advertising availability to new clients, and for scheduling supervision meetings. Answer in general terms; we understand your schedule will likely change based on class requirements. Photograph for Website Profile Drop a file here or click to upload Choose File Maximum file size: 52.43MB Posting your photo on our website is not mandatory but it is recommended. Clients like to see their counselor as part of their process of looking for support. If you don’t have a photo now but want to share it later, you can email it in. Will you need accommodations for a disability, or specific life circumstance? Please share them here. What languages do you speak, that you would be comfortable offering therapy in? Please list them in the order of proficiency. Submit If you are human, leave this field blank.