Supervision Application Form

Please complete the supervision application form.

Only complete forms with all components will be considered.

Today's Date *

First Name *

Last Name *

Phone *

Email *

What Type of Licensure Are You Ultimately Seeking? *

Do you currently hold your Virginia Resident (in Counseling or MFT) License? *

At what company(s) will you be completing Residency hours? *

List any certifications or specialized trainings you hold and date completed (ie. EMDR, Certified Play Therapist, Gottman, etc)

What professional memberships do you hold (ie. ACA membership, VCA membership, AACC membership, etc)?

We ask our supervision applicants to create and share a video cover letter. Here's how to make a video!

Video Cover Letter Link

Please attach your professional resume and three professional references below in PDF format. *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Counsel RVA therapists and/or office staff communicating with me via email or text message. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

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