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Request to Change or Add Supervisor
Name
*
*
Program
*
Licensure pathway you are accruing hours toward
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Will your current supervisor or consultant continue working with you?
*
A
Yes
B
No
Requested effective date
*
Reason for this change or addition
*
Have you already begun working with this person?
*
A
Yes
B
No
Meridian Email
*
Request Details
Current supervisor or consultant name
*
What are you requesting?
*
Fieldwork Site Information
Site Name
*
Site Website
*
Site contact person name
*
Site contact person email
*
Site Address line
*
*
*
*
Country
*
Site Phone Number
*
Is this site listed on Meridian's Previously Approved Field Placement Sites list?
*
Is the site one of the following?
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Date
*
Signature
*
Signature
Proposed Supervisor or Consultant
Full name
*
Professional title and credentials
*
Email
*
Phone
*
Role
*
Relationship to the site
*
Is this person a current or former Meridian student or alum?
*
A
Yes
B
No
C
Unsure
Describe the proposed supervision or consultation arrangement
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Proposed supervisor’s or consultant’s current résumé
*
Click to choose a file or drag here
License Details
License type
*
License number
*
Licensing state or jurisdiction
*
Are you aware of any restrictions on this license?
*
A
Yes
B
No
C
Unsure
Supporting Documents
Please upload the following documents (PDF, DOC, DOCX):
- Current supervisor license
- BBS Responsibility Statement (CA MFT or LPCC)
- BOP Supervisor Agreement (CA psychologist)
- Off-site supervisor letter of agreement
- Supervisor malpractice face sheet, if the supervisor isn’t covered by the site’s insurance
*
Click to choose a file or drag here
Are you proposing an additional supervisor or consultant?
*
A
Yes
B
No
I understand that submitting this request does not itself constitute approval.
*
I acknowledge
Submit