Professional Registration for Supervision

Supervision and Consultation

To help us ensure that these offerings are appropriate for your professional needs, please complete the registration form below.

Our team will review your professional information before enrollment.
If your registration is approved, you will receive a separate email with payment and scheduling instructions.

Submitting this form does not confirm enrollment or reserve a session.
You will receive a confirmation email after we review your submission.

Professional Registration Form

Registration Form

First

Last

Email Address

Phone Number

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Degree & Professional Credentials

License Type & Number

Issuing State / Jurisdiction

License Expiration Date

Years in Licensed Practice

Key Topics & Objectives: List specific clinical questions or topics you hope the consultation group will address:

Case Presentations: Are you interested in presenting de-identified cases for peer feedback?

Which service are you interested in?

Individual Supervision with Dr. Lorna Myers — 45 minutes — $350

Individual Supervision with Dr. Julia Doss — 45 minutes — $350

Group Consultation — First Session — 90 minutes — $100

Group Consultation — 5-Session Module with Certification — $500

Professional Eligibility Confirmation

I confirm that I am a licensed mental health or medical professional seeking professional consultation, supervision, or training. I understand that these services are not intended for patients or family members seeking clinical care.

I understand that submitting this form does not guarantee acceptance or enrollment. My registration will be reviewed before payment instructions are provided.

Privacy / communication

I agree that the information submitted through this form may be used to review my eligibility and contact me regarding this registration.