provisional supervision application form · provisional supervision application form thrive...

Provisional Supervision Application Form Thrive Counseling & Consulting, PLLC 1611-B Owen Drive Fayetteville, NC 28304 Full Name ___________________________________________________________________________________________________ Current Address____________________________________________________________________________________________ Cell # ________________________________________________________________________________________________________ Email: _______________________________________________________________________________________________________ School attended: __________________________________________________________________________________________ Date graduated (DD/MM/YYYY): _________________Degree Awarded: ___________________________________ I am requested to complete my hours for licensure in (state):_________________________________________ Basic hour requirements: ______ direct client _______indirect _________ supervision License #______________________ Type of License (i.e. MFT, LPC etc.)_____________NPI #__________________ Practice Location #1 ______________________________________________________________________ Work POC: ________________________________________________________________________________________________ Print Supervisor’s Name Phone Email Practice Location #2 ______________________________________________________________________ Work POC: ________________________________________________________________________________________________ Print Supervisor’s Name Phone Email Emergency Contact Name: ___________________________________________ Phone: ___________________________________________________ Include the following documents or information Copy of Driver’s License Copy of Social Security Card (Copy of passport can be substituted for SSN Card & DL) Copy of current professional liability insurance with policy # Interns Only: Would you like your pay to go to direct deposit? ___Yes ___ No If yes, ABA routing number______________________ Account Number___________________________________ Bank Name________________________________________________________________________________________

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ProvisionalSupervisionApplicationFormThriveCounseling&Consulting,PLLC

1611-BOwenDriveFayetteville,NC28304

FullName___________________________________________________________________________________________________CurrentAddress____________________________________________________________________________________________Cell#________________________________________________________________________________________________________Email:_______________________________________________________________________________________________________Schoolattended:__________________________________________________________________________________________

Dategraduated(DD/MM/YYYY):_________________DegreeAwarded:___________________________________Iamrequestedtocompletemyhoursforlicensurein(state):_________________________________________ Basichourrequirements:______directclient_______indirect_________supervisionLicense#______________________TypeofLicense(i.e.MFT,LPCetc.)_____________NPI#__________________PracticeLocation#1______________________________________________________________________WorkPOC:________________________________________________________________________________________________ PrintSupervisor’sName Phone EmailPracticeLocation#2______________________________________________________________________WorkPOC:________________________________________________________________________________________________ PrintSupervisor’sName Phone EmailEmergencyContactName:___________________________________________Phone:___________________________________________________Includethefollowingdocumentsorinformation

CopyofDriver’sLicenseCopyofSocialSecurityCard(CopyofpassportcanbesubstitutedforSSNCard&DL)Copyofcurrentprofessionalliabilityinsurancewithpolicy#

InternsOnly:Wouldyoulikeyourpaytogotodirectdeposit?___Yes___NoIfyes,ABAroutingnumber______________________AccountNumber___________________________________ BankName________________________________________________________________________________________

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