Minnesota Association for Children's Mental Health

MACMH Supervision Series

Thank you for your interest in MACMH's Supervision Series.
Please fill out the application for COHORT 2.

If you have any questions please email Amanda Xiong, Professional Development Director, axiong@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
Organization/Agency Name *
Organization/Agency Name Address *
Job Title *
Please Upload your Resume *
Do you require any accommodations? (e.g., ASL interpretation, closed captioning, etc.)
Why are you interested in this program? *
What do you hope to achieve or learn by participating in this program? *
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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