Clinical supervision

Name (required)

Additional names if group supervision

Contact telephone number(s) (required)

Email (required)

RCSLT membership number (required)

HCPC number (required)

Name of NHS Trust / other employer (required)

Manager's name (required)

Employer address (required)

Employer telephone (required)

SLT in Independent Practice:

Name of practice (required)

Practice address (required)

Name and address / email address to which invoice should be sent (required)

Work setting (required)

Current client group:

Children under 7Older primary school age childrenSecondary school childrenAdults

Special interests

Do you currently have any other clinical supervision? (required)

YesNo

If yes, please give details:

Any preferred day of the week? Or please state if no preference:

Any therapeutic approach or model that you work with or are interested in developing your skills in:

How often you would like sessions and over what period of time (if known):

Preference for face-to-face or Skype:

Face-to-faceSkype

Please give an indication of your experience to date and any post-grad CPD in stammering (required):

Please comment on what you are hoping to gain from supervision (required):

When the start of supervision is agreed the name and email address of the invoicee will be sent to the Finance Department at Whittington Health. The invoicee will be contacted by that department to make payment, either by cheque, bank transfer or credit/debit card payment.

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