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teachSBIRT Curriculum Infusion Packet (CIP)
OnDemand
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About
Services
FAQs
Academics
Advising
Faculty
Student Support Programs
CASAT Learning
Meet the Team
Wolf Pack WILD
About
Meet the Team
WILD Living and You
WILD Living in Community
Podcasts
Grants & Contracts
Resources
teachSBIRT Curriculum Infusion Packet (CIP)
OnDemand
Contact
Supervisor OnDemand Application
1
Request Type
2
Supervisor Information
3
Edits/Changes
4
Removal Request
Name
(Required)
First
Last
Email
(Required)
Enter Email
Confirm Email
What type of a request is this?
(Required)
Publish a new supervisor listing
Edit an existing supervisor listing
Remove an existing supervisor listing
Section 1 - Contact Information
Name (as displayed on post)
First
Last
Credentials / License Number(s)
Specialty Credentials
Years in Practice
Years in Supervision
Attach Photo Here
Accepted file types: jpg, jpeg, png, Max. file size: 25 MB.
Phone Number
Email Address
Practice / Organization Name
Website / LinkedIn URL
City
State
Preferred Contact Method
(Required)
Phone
Email
Either
Best Time to Reach You
Section 2 - Type of Intern Accepted
Select all intern types you are currently accepting new interns for supervision:
(Required)
Licensed/Certified Alcohol & Drug Counselor (LADC/CADC)
Marriage & Family Therapist (MFT)
Certified Professional Counselor (CPC)
Certified Problem Gambling Counselor (CPGC)
Licensed Clinical Alcohol & Drug Counselor (LCADC)
Other (please specify)
Other Intern Type:
(Required)
Maximum number of interns accepted at one time:
Primary Supervisor:
(Required)
Secondary Supervisor
(Required)
Section 3 - Supervision Details
Supervision Format (select all that apply):
(Required)
Individual (1:1)
Group
Both Individual & Group
Telehealth / Remote
Supervision Frequency & Timing:
(Required)
Clinical Approaches / Methods:
(Required)
Cognitive Behavioral Therapy (CBT)
Dialectical Behavior Therapy (DBT)
Motivational Interviewing
Trauma-Informed
Existential
Narrative Therapy
Strength-Based
Person-Centered
12-Step Facilitation
Integrated Dual Diagnosis
Other (please specify)
Other Clinical Approach / Method
(Required)
Areas of Expertise / Specialization:
(Required)
Substance Use Disorders
Problem Gambling
Co-Occurring Disorders
Mental Health
Adolescents / Youth
Criminal Justice / Re-Entry
LGBTQ+ Populations
Trauma / PTSD
Veterans / Military
Culturally Specific Populations
Opioid Use Disorder / MAT
Prevention Services
Additional areas of expertise:
Section 4 - Supervision Fees
Hourly Supervision Fee
(Required)
Group Supervision Fee
(Required)
Section 5 - About the Supervisor
Supervisor Bio
Tell interns a little about yourself! Share your background, what you enjoy about supervision, and what interns can expect working with you.
Section 6 - Availability
Currently accepting new interns:
(Required)
Yes - Immediately
Yes - Starting (specify date below)
Waitlist Only
If starting at a future date, specify:
(Required)
MM slash DD slash YYYY
Preferred days / hours for supervision meetings:
Section 7 - Acknowledgment
By submitting this form, I confirm:
(Required)
• The information provided is true and accurate to the best of my knowledge.
• I understand I need to follow the requirements of the intern’s board.
• I acknowledge I am responsible for updating my post to remain current and relevant.
• I understand that my post may be removed by CASAT staff at any time if information becomes outdated or inaccurate.
I understand and confirm
Section 1 - Updates
What is the link to your existing listing?
(Required)
What would you like to edit about your current supervisor listing?
(Required)
Section 2 - Acknowledgment
By submitting this form, I confirm:
(Required)
• The information provided is true and accurate to the best of my knowledge.
• I understand I need to follow the requirements of the intern’s board.
• I acknowledge I am responsible for updating my post to remain current and relevant.
• I understand that my post may be removed by CASAT staff at any time if information becomes outdated or inaccurate.
I understand and confirm
Section 1 - Removal Request
What is the link to your existing listing?
(Required)
Removal Request
(Required)
Please remove my existing supervisor listing
Section 2 - Acknowledgment
Please read and confirm each statement below before submitting your removal request:
(Required)
• I understand that removing my post is permanent and my listing will no longer be visible to interns on Supervisor on Demand.
• I understand I can repost at any time by submitting a new Supervisor on Demand Request Form.
I understand and confirm
