APPLY FOR GROUP SOUP Full Name * First Name Last Name Preferred Pronouns Email * Phone * (###) ### #### Age * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Undergraduate Experience * Degree Type, School, Graduation Date - Ex: Loyola University, BSW, 2010 Graduate Experience * Degree Type, School, Graduation Date - Ex: Loyola University, MSW, 2010 Do you currently have your clinical license? * Yes No If yes, please provide the type of license (LPC/LCPC, LSW/LCSW) and number Number of approximate accumulated clinical hours * This helps us understand your progress toward clinical licensure Have you applied yet to sit for your exam? * Yes No If you are preparing to sit for your clinical exam (LCSW/LCPC) in the future, please tell us about your current plan for doing so. * Specifically, have you taken the exam and did not pass? When do you plan to take the exam? Where are you in the process of collecting and tracking hours? Do you have a supervisor who has or has not signed off on these hours? What kind of support do you think you will need from the Wolf Pack team? Please provide as many details as you can. Please describe your clinical areas of interest * Please describe your current clinical work * Employment Status * Please include the name of your current employer, your role there, and length of employment A statement reflecting why you are interested in the Group Soup program? * Please tell us about your goals for joining Group Soup * Check all that apply to you. Increasing preparedness to sit for your clinical exam (LCPC/LCSW) Gaining more direct practice experience Increasing connections with other clinicians in the field Having stable and high-quality supervision Increasing my knowledge of relevant clinical subject matter Based on your current and past clinical experiences, what are your expectations from clinical supervision at Wolf Pack? * What subject matter areas are you interested in developing knowledge and skills around? * Are you available for Group Soup sessions on Thursdays from 6-7 pm? * Yes No If no, please provide 3-4 other options for when you are available. * Which settings would you consider for Group Soup engagement (weekly sessions, one-on-ones, etc.)? * In-person Online Hybrid In an ideal world where all stars are aligned, would you choose an in-person-only program? * Yes No Will you need supervision after Group Soup ends? * Group Soup is an 8-10-month-long intensive fellowship program. Yes No Do you work for a non-profit organization? * Yes No If yes, do you think your team could benefit from bringing Group Soup into your organization? * Yes No Is there anything else you would like to share? Thank you for applying to Group Soup! A member of our programming team will get back to you within the next week to discuss the next steps.
