Participant’s Profile Sheet

Participant’s Profile Sheet (Please Complete & Return)

Your Name: Phone #__________________

Address:___________________________________________________________

Email Address:______________________________________________________

Bachelor’s Degree:___________________________________________________

University Bachelor’s Earned From: _____________________________________

Master’s  Degree:____________________________________________________

University Master’s Earned From: ______________________________________

Which 3 types of clients do you have an interest in servicing?

__________________________________________________________________

What are 3 of your current counseling strengths/interests?

__________________________________________________________________

What are 3 of your current counseling weaknesses/fears? __________________________________________________________________

What are 3 things you hope our supervisory program will provide you with?____________________________________________________________________________________________

Please place a check mark next to the program(s) you are interested in

_____Basic Supervision   _____Professional Development _____Professional Residencies

___ Group Supervision _____ Facilitate Workshops _____ NCE Study Course

___ Individual Supervision _____ Book Club _____ Counseling Residency

___ Communication _____ Scholarly Writing/Research    ______ Other

Recco S. Richardson Consulting, Inc. • Licensure Educational Training (LET)