Supervisor Application

Basic Information

Full Name *

Title/Position *

Email *

Work Phone Number *

Work Address Line 1 *

Work Address Line 2

Country

Province

State

Province/State *

Do not use abbreviations. Please write out the province/state name in full.

City *

Postal/Zip Code *

Professional Association/Affiliation

Counsellor

Psychologist

Social Worker

OtherOther

Name of Professional Association & Regulatory Body

Code of Ethics

Professional Standing

To the best of my knowledge, I am registered or licensed to engage in independent counselling practice (i.e., cannot be Qualifying status or Provisional status).

Clinical Supervision Information

Highest Degree in Clinical Counselling/Psychology/Social Work (must have minimum of a master’s degree)

Year Obtained

Years of Clinical Counselling Experience

Do you have one full year of clinically-supervised experience in post degree?

Yes

Years of Experience in Providing Clinical Supervision

Applicable Training in Supervision

Other Notable Information

What supervisory role will you play in this practicum?

Primary Supervisor

Co-Supervisor

Onsite Supervisor

External Supervisor

You have selected External Supervisor, please identify the person with whom you will have regular weekly or bi-weekly contact:

Full Name *

Title/Position *

Email *

Work Phone Number *

Will you be supervising more than one Yorkville University student concurrently?

Yes

Supervisor Agreement

I acknowledge that I am not the Practicum Student's direct Employment Supervisor and/or current therapist (i.e., refraining from dual relationships as outlined in the Supervisors Practicum Guide)

Yes

I agree to uphold the requirements and procedures outlined in the Supervisors Practicum Guide.

Yes

All potential supervisors are required to provide a copy of (1) current CV or Resume and (2) registration/certification/licensure document to be reviewed and approved by the Department of Field Training, even if they have provided it previously. Please email these items to our Practicum Liaison [email protected] in order to complete the application process.

MACP Practicum Portal

MACP Practicum Portal

Basic Information

Clinical Supervision Information

External Supervisor

Ontario Practitioners

Supervisor Agreement

Select an AskYU Category

Contact Us

Form Submissions

General Help

Menu