Supervision Form Date MM slash DD slash YYYY Email Name First Last Date of Birth MM slash DD slash YYYY Please check the box indicating you have read the below information: I have read the information below:Dear Client, Northland Counseling Center, Inc is a Rule 29 Licensed Mental Health Clinic. We employ a multidisciplinary mental health team with a broad spectrum of training and experience. Credentials for all of our staff are available at the front desk or online. As part of our multidisciplinary team approach, we employ mental health professionals, mental health clinical trainees and interns. All of the staff participate in consultation with the team and their individual clinical supervisors. Some of our mental health staff are credentialed by certain health plans and not by others. The following may apply to the provider you will be working with. 1) Doctoral Intern, supervised by a Mental Health Professional 2) Clinical Trainee, supervised by a Mental Health Professional 3)Licensed Mental Health Professional, NOT credentialed by your health plan AND supervised by a credentialed provider 4) Practicum Student, supervised by a Mental Health Professional 5) Internship Student, supervised by a Mental Health Professional One of the supervising providers may be: Angie Baratto, MA, LPCC Amie Madl, MA, LMFT, RPT-S Laura Maxwell, MSW, LICSW Danielle Krasaway, MS, LPCC Brandi Worrath, MS, LPCC Dessa Bergan, MSW, LICSW Jennifer Alstad, MS, Ed., LMFT Allison O’Hara-Meyer, Psy.D., LP Brea Wallaker, MSW, LICSW
