Email

City/County of Residence

Name of Current Employer/Agency or Private Practice:

If other, please specify

Primary clinical issues of presenting problems in clients:

(e.g. anxiety, trauma, depression, relationship issues, etc.)

Date of initial license

Preferred Meeting Days/Times:

How many supervision hours have you completed so far (if any)?

How many clinical hours are you currently completing per week?

What are your main goals for supervision?

What specific skills or areas of professional growth would you like to focus on?

What do you hope to gain personally and professionally from our supervision relationship?

What are your short-term professional goals (next 6–12 months)?

What are your long-term professional goals (next 3–5 years)?

Describe your counseling experience so far (settings, populations, length of time, etc.):

Which counseling theories or approaches do you identify with most?

What are your greatest strengths as a counselor-in-training?

What areas of counseling practice do you currently find most challenging?

How do you handle feedback or constructive criticism?

What qualities or traits are you hoping your supervisor will have?

Supervision Interest Questionnaire

Help me get to know you.