Name* First Last Full Agency Name* Agency Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work Phone*Home Phone*Cell Phone*Preferred Email* Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have an MSW degree?* Yes No What is your current social work licensure status (e.g. Connecticut LCSW, LMSW, Massachusetts LICSW, etc.)* Are you currently working as a supervisor?* Yes No Specify the type of setting you currently work in as a supervisor (select all that apply). If you select "other service settings" below, please specify* Addictions services setting Children and family services setting Health care services setting Justice services setting Mental health care services setting Veterans services Other services setting If you selected "other service settings" above, please specify: Please provide a single number to represent your best estimate of the annual total number of clients collectively served by you and the people you supervise (your team). Answer with a specific estimate number (i.e. 250), not a range of numbers.*Number of years working at your current organization (single number, not a range).* Number of years serving in a supervisory role in your career (single number, not a range).* Number of years serving in a supervisory role in your current position (single number, not a range).* Current number of social work supervisees: MSWs, LMSWs, LCSWs, LCSW-R (single number, not a range):* Current number of BSW supervisees (single number, not a range):* Current number of other staff you supervise (single number, not a range):* Are you agreeing to attend all SWPF workshops?* Yes No How will you be paying if you are selected for this program?* Personally, with reimbursement from the agency Personally, without reimbursement Agency will pay directly Are you agreeing to complete both pre- and post-program assessments of supervisory practices? (All survey data will be de-identified and reported only in aggregate. Your name will not be linked in any way with your responses to this survey.)* Yes No Please read:* By clicking this box, you are affirming the accuracy of your statements contained within this application. Please upload a copy of your resume.* Drop files here or Select files Accepted file types: pdf, doc, Max. file size: 100 MB. CommentsThis field is for validation purposes and should be left unchanged.