Workwise – Technology Based Clinical Supervision – R3.2

Name*

First Last

Credentials

Agency/Organization*

Job Title/Position*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone Number*

Cell Phone Number*

(NFARtec Staff will be sending weekly SMS text messages related to course content. By inputting your phone number, you consent to receive text messages sent through an automatic telephone dialing system.)

Email Address*

Enter Email Confirm Email

Password*

Enter Password Confirm Password

Strength indicator

Are you currently providing clinical supervision in a behavioral health setting?*

Yes
No

How many years of clinical supervision experience do you have?*

Have you ever had any TBCS training?*

No
Yes

Are you currently providing technology-based clinical supervision?*

Yes
No

If yes, what technology(ies) are you using to provide clinical supervision (i.e., video, phone)?*

Your Gender:

Female
Male
Transgender

Do you identify as LGBTQ+ (Lesbian, Gay, Bisexual, Transgender, or Queer)?*

Yes
No

Are you Hispanic or Latino/a?*

Yes
No

What is your race? (Select one or more):*

Alaska Native
American Indian
Native Hawaiian
Other Pacific Islander
Asian
White
Black or African American
Other

Please Specify:*

Do you hold a supervisory role in your current position?*

If yes, you may be contacted via email by an external evaluation team to gather feedback about ways the Central East ATTC can help support your organization’s mission through advancing the substance use treatment workforce.

Yes
No

By checking here you are indicating that you understand the pre-requisite and technology requirements as well as the time commitment to participate in this training.

I understand the time commitment involved and agree to fully participate.