Remote Supervision ApplicationPlease complete this form for pre-screening purposes. If all looks good, we will reach out to you via email! Name * First Name Last Name Email * Preferred Pronouns Desired Certification * BCBA BCaBA Have you started your qualifying behavior analytic coursework? * Yes Not yet If not yet, when is your program start date? Your program's website * We will need this to confirm whether it is considered a verified course sequence (VCS). http:// If applicable, how many fieldwork hours have you already completed? We will ask for documentation that reflects this. Are you currently employed and practice behavior analytic duties? * Yes No How many hours do you work per week? Describe your behavior analytic role. * Do you currently work under a BCBA? * This will help determine which fieldwork verification form we will be signing each month. Yes No If yes, how many? Desired Fieldwork Type * -Supervised Fieldwork: BCBA (2000 hours), BCaBA (1300 hours) -Concentrated Supervised Fieldwork: BCBA (1500 hours), BCaBA (1000 hours) -Not sure? Don't worry, we'll explain it all so you can make the best informed decision for you! Supervised Fieldwork Concentrated Supervised Fieldwork Not sure State * This will help determine whether our supervisors will be eligible to supervise you remotely. At this time, we will only be seeing trainees residing in the US. Timezone PST CST EST MST AZ Time HST Your Availability * Trainees are expected to dedicate at least 1 hour/week to meet with their supervisor. Do you have reliable wi-fi? * Yes No Any cultural holidays for us to consider For scheduling purposes Any ongoing/potential barriers to supervision Anything else you'd like us to know Thank you! Please allow up to a week to receive an email that will address the next steps.
