Counseling Services in Lake Charles

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Call Us 337-965-1336

Home
Staff
Our Services
PLPC Supervision
Contact

PLPC Supervision Inquiry Form

Contact Us

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1. Basic Identifying Information

Full Name

PLPC

Email

Phone

Preferred Method of Contact

Email

Phone

Text

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2. Current Professional Status

Current Employer

Work Setting

Private Practice

Community Agency

School-Based

Hospital/Medical

Other

Employment Status

Full-time

Part-Time

Contract

Start Date

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3. Supervision Requirements

Date PLPC License Issued:

Supervision Hours Accrued to Date

Supervision Hours Remaining

Anticipated Completion Timeline

Are you currently under supervision?

Yes

No

If Yes

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4. Clinical Focus & Experience

Primary populations served (check all that apply):

Children

Adolescents

Adults

Couples

Families

Common presenting concerns treated

Specialized training

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5. Practice & Ethical Considerations

Do you carry individual professional liability insurance?

Yes

No

Have you ever had an ethical complaint, board investigation, or disciplinary action?

Yes

No

New Field:

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6. Supervision Preferences

Preferred supervision format:

Individual

Group

Combination

Preferred supervision method:

In-person

Virtual

Preferred supervision frequency:

Weekly

Bi-weekly

Days/Times

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7. Expectations & Goals

Supervision

Areas you need the most support in (check all that apply):

Diagnosis

Treatment Planning

Cocumentation

Ethics

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Clinical Skills

Private Practice Prep

Long-term professional goals

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8. Financial & Commitment Readiness

Are you able to commit to consistent supervision for the duration of licensure?

Yes

No

Are you able to pay supervision fees as agreed?

Yes

No

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9. Financial & Commitment Readiness

How did you hear about this LPCS?

More info

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10. Attestation & Signature

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I certify that the information provided is accurate and complete. I understand that submission of this form does not guarantee acceptance into supervision.

Applicant Signature:

Date:

Thank you for contacting us.
We will get back to you as soon as possible.

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Contact Information

114 State Street

Lake Charles, LA 70615

Tflcs2023@gmail.com

Business Hours

Mon - Sat: Appointment Only
Sunday: Closed

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All Rights Reserved | Transforming Lives Counseling Services, LLC

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