Bessemer: 7555 Dickey Springs Rd | Birmingham: 1731 1st Ave N, Suite 2012 Locations in AL

ALC Supervision Program Application

Complete this application to join our ALC Supervision Program. All fields marked with * are required.

Personal Information

Full Legal Name *

Preferred Name (Optional)

Date of Birth (Optional)

Phone Number *

Email Address *

Street Address (Optional)

City (Optional)

State (Optional)

ZIP Code (Optional)

Emergency Contact (Optional)

Name

Relationship

Phone

Educational Background

Master's Degree (Optional)

University/Institution (Optional)

Graduation Date (Optional)

Specialization/Concentration (Optional)

Licensure Information

ALC License Number (Optional)

ALC Issue Date (Optional)

ALC Expiration Date (Optional)

Exam Type (Optional)

Exam Date (Optional)

Current Employment

Current Employer (Optional)

Position/Title (Optional)

Employment Start Date (Optional)

Work Setting (Optional)

Hours Per Week (Optional)

Population Served (Optional)

Supervision History

Have you received supervision before?

Professional Goals

Career Goals and Objectives (Optional)

Areas of Interest/Specialization (Optional)

Preferred Therapeutic Approaches (Optional)

Timeline for LPC Licensure (Optional)

Supervision Preferences

Preferred Supervisor (Optional)

Meeting Preference (Optional)

Preferred Days/Times (Optional)

Plan Selection *

Select Your Supervision Plan

Professional References (Optional)

Please provide two professional references (professors, supervisors, or colleagues).

Reference 1

Name

Title

Organization

Phone

Relationship

Reference 2

Name

Title

Organization

Phone

Relationship

Additional Information

How did you hear about Hope Counseling Center? (Optional)

Accommodations Needed (Optional)

Additional Comments or Questions (Optional)

Required Documents

Note: Please upload the following documents to complete your application. All files must be in PDF format and under 10MB each.

ALC License Copy *

Upload a clear copy of your Associate Licensed Counselor license

Resume/CV *

Upload your current resume or curriculum vitae

Graduate Transcripts (Optional)

Upload unofficial or official transcripts from your master's program

By submitting this application, you agree to our supervision policies and acknowledge that all information provided is accurate and complete.