Registration: Clinical Supervision and Leadership

Name*

First Last

Credentials*

Agency/Organization*

Current Position*

Mailing Address*

City State ZIP Code

Email*

Enter Email Confirm Email

Password*

Enter Password Confirm Password

Strength indicator

Daytime Phone Number*

Mobile Phone Number*

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

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

Yes
No

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

Please enter a number from 0 to 99.

What do you hope to learn by participating in this online learning series?*

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?*

Yes
No

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