LPC‑ASSOCIATE / SUPERVISION & 1099 FORM

Full name

Email

Phone Number

Current City & State

Preferred Contact Method

Call

Text

Email

What Are You Seeking?

Where are you currently working?

What populations do you serve?

What theoretical approaches or modalities do you use?

What are your strengths as a clinician?

What areas do you want to grow in?

For LPC‑A supervision, Have you passed the NCE?

Projected start date for supervision:

What are your goals for your LPC‑A journey?

What do you need from a supervisor to feel supported and challenged?

Supervision format you are seeking:

Weekly

Biweekly

Group

A mix

Are you available for 4–6 clients per week?

Are you comfortable with telehealth?

Are you open to in‑person sessions in Colleyville?

What days/times are you available?

What clinical populations do you feel most confident with?

What support do you need to be successful in a part‑time role?

What are the top 3 challenges in your practice or business right now?

What outcomes are you hoping to achieve?

What’s one thing you want clarity on immediately?

Anything else you want me to know before we schedule?

Would you like to receive updates, resources, or program announcements from DLR Counseling Group?

Yes, I want to choose what I receive

No, I do not want to receive emails

If yes, which of the following would you like to receive?

Grief & Loss Workshops

Men’s Emotional Health / Brotherhood 2.0

Couples & Relationship Work

Mental Health Education & Tools

Free Resources (guides, videos, downloads)

Upcoming Events & Live Experiences

DLR Counseling Group Updates

I understand this form is for supervision, employment, or professional services — not therapy

READY TO GROW YOUR CLINICAL CARRER?