OpenGate Supervision Application Form

To Apply:

Please fill out this application form completely. Kathleen will reach out to you to set up an interview if we have room in our program and feel that you might be a good fit with us, and vise versa. After meeting with Kathleen, the next step would be a second interview with Kate, to give us a better sense of how we might support you. If we all feel that the fit is right, we will begin the onboarding process! For more information, reach out to Kathleen or Kate.

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Thank you for your response. ✨

Name

Mailing Address

Phone

Application is for a Graduate Level Practicum/Internship

Application is for Post-Grad Supervised Billing & Clinical Supervision

Application is for regular on-going Clinical Consultation

If you are in a graduate program, what is your school/program’s name, what credential do you seek, and when do you expect to be done?

If you are a graduate with a Master’s degree, where, when, and in what, specifically, did you get your degree?

What is your clinical focus or practice specialty?

List all previous relevant experience:

Are you currently under Supervision? If so, where and with whom? Please describe why you are making a change.

Do you currently have a caseload of clients you see? If so, how many, and what types of insurance are you currently billing to?

When are you hoping to begin at OpenGate?

Describe your dream practice or end goal

Please describe any professional development interests (e.g., specific areas of counseling, certifications, clinical modalities, etc.)

What attracts you to private practice? Do you describe yourself as an entrepreneur?

Have you ever had disciplinary action against you by a school, employer, or regulating entity? Is so, please describe in detail.

Please provide at least one reference from a previous supervisor or academic program representative. Provide a name, relationship, and email

Choose all that apply:

I am seeking an LADC credential I am seeking an Clinical Social Work credential I am seeking an LCMHC credential

By clicking here, I attest that all information provided is true.

Thank you for your interest in OpenGate! Stay tuned for our reply!