MACMH Supervision Series

Welcome!

Thank you for your interest in the MACMH Supervision Series application. We’re excited to support your professional development through this training opportunity. Please take a moment to complete this form carefully to help us determine your eligibility and process your application efficiently.

Application Opens: Wednesday, November 26, 2025
Application Closes: Friday, January 9, 2026
You will hear about your acceptence by approximately Friday, January 23, 2026

Confidentiality Statement:
The information provided in this form will remain strictly confidential and will be used only to determine eligibility and support the application process for the MACMH Supervision Series. Your responses will not be disclosed beyond the grant administration team.

If you have any questions please email Abbey Joyner, Professional Development Program Coordinator, ajoyner@macmh.org

This training is offered with grant support from the Minnesota Department of Health Office of Rural Health and Primary Care.

Link to your user record
Please either sign into your user account, or use the same first name, last name and email combination on all MACMH forms.
First Name *
Last Name *
Email Address *
Which MN Board are you seeking licensure? *	LPCC: Licensed Professional Clinical Counselor LMFT: Licensed Marriage and Family Therapist LP: Licensed Psychologist LICSW: Licensed Independent Clinical Social Worker
Active License Number *
Race/Ethnicity (Check all that apply): *	African / Black / African-American Arab / Arab-American Asian / Asian-American Ashkenazi Jewish Hispanic / Latinx / Chicanx Multi-Racial Native American / Indigenous / American Indian / Alaska Native Native Hawaiian / Pacific Islander White / Non-Hispanic
Race/Ethnicity: Let me share
Gender Identity (Check all that apply): *	Cis Man Cis Woman Intersex Nonbinary /Genderfluid / Genderqueer Trans Man Trans Woman Two-Spirit
Gender Identity: Let me share
Are you internationally born (i.e., born outside of the United States)?	Yes No
Are you a person with a disability or chronic condition?	Yes No
If yes, please provide a brief description:
Organization/Agency Name *
Organization/Agency Name Address *
Job Title *
Please Upload your Resume *
Why are you interested in this program? *
Please provide a description of how you qualify under the stated eligibility conditions. *Eligibility Participants must, be Minnesota residents. be LPCC, LICSW, LMFT, or LP holders. be members of an underrepresented community as defined by Minnesota State Statute section 148E.010, Subd.20: “Underrepresented community” means a group that is not represented in the majority with respect to race, ethnicity, national origin, sexual orientation, gender identity, or physical ability. agree to deliver at least 25% of their yearly patient encounters to state public program enrollees or patients receiving sliding fee schedule discounts through a formal sliding fee schedule meeting the standards established by the U.S. Department of Health and Human Services.
How will this program help you achieve your professional goals? *
How will you balance the 15-week intensive training with your work and daily life? *

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Founded in 1989, MACMH is a 501(c)(3) nonprofit whose mission is to promote positive mental health for all infants, children, adolescents and their families.

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