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Apply For Supervision
Apply For Supervision
First name
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Last name
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Phone
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Email
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City & State
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Which certification are you pursuing?
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BCBA
BCaBA
University/ Program Name
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Expected Graduation Date
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Behavior Blueprint™ provides supervision for UNRESTRICTED fieldwork hours only. Which best describes your situation?
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I am currently accruing unrestricted hours
I plan to begin accruing unrestricted hours
I am completing restricted hours elsewhere and seeking unrestricted supervision only
Approximate number of unrestricted hours completed (if any)
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Current fieldwork setting(s):
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Clinic
School
Home based
Other (describe)
Select all activities you currently have access to (or expect to have access to):
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Data analysis & graphing
Behavior plan development
Functional behavior assessments
Parent or caregiver training
Staff/RBT training or feedback
Program modification
Ethical decision-making scenarios
Briefly describe your current role and responsibilities:
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Are you able to commit to:
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Monthly individual supervision
Monthly group supervision
Active participation and preparation
What are you hoping to gain from unrestricted supervision?
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Why are you specifically seeking unrestricted supervision at this stage?
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Describe how you handle feedback and clinical correction:
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Have you ever been dismissed from a supervision relationship?
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No
Yes (explain)
Please initial to acknowledge:
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I understand this supervision is unrestricted hours only
I understand acceptance is not guaranteed
I agree to follow BACB ethical and supervision requirements
Signature
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Date
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Month
Day
Year
Submit
*Please complete the application below. Submission does not guarantee acceptance
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