EFT Supervision On-Demand Form — SUPERPOWER ALLIANCE

If a Supervisor is available at one of your selected times, they will reach out to you
directly to schedule a session with you.

Name

First Name

Last Name

Phone

Country

(###)

###

####

Your Time Zone

Date/Time - First Choice

MM/DD/YYYY HH:MM am/pm

Date/Time - Second Choice

MM/DD/YYYY HH:MM am/pm

Date/Time - Third Choice

MM/DD/YYYY HH:MM am/pm

I would like to request supervision from:

I understand that this is not for actual emergencies (need to report abuse, actively suicidal client, etc).

Yes

I understand that this supervision can’t be counted as hours toward certification or licensure.

Yes

I have liability insurance and will provide proof of insurance if requested.

Yes