Application for Supervision - Daniel Brake, LMFT-S

Thank you for your interest in working with me! Please take a few minutes to complete the application below.

If you have any questions or concerns, feel free to email me directly at: daniel@austinlmft.com

Name

First

Last

Email *

Phone Number

License number (if issued) or expected issuance date *

Liability Insurance Carrier (with policy number) *

website (optional)

Preferred Client Population *

Preferred Clinical Modalities *

Education

Please list all undergraduate and graduate institutions attended with degree conferred and date of completion

Additional Training

Please list any additional trainings, certifications or educational opportunities you have in the mental health field

Experience *

Please list all relevant (in the field of mental health) work experience, research, internships, and practicum sites with beginning and end dates

References *

Please provide 3 references from an academic or clinical setting. Include their full name with title, phone number, email address, and the nature of their relationship with you.

Why did you decide to become a therapist?

What do you hope to get out of your supervision experience?

Phone