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The NC 3P Case Conference Application

Date(Required)

All fields are required!

Name(Required)

First Last

Work Address(Required)

Street Address City State ZIP Code

Mobile Phone(Required)

Email(Required)

Educational Background (College & Graduate Programs)(Required)

Dates

Degree

Institution

Please click the plus sign at the end of the row to add up to 4 additional lines.

Current Work Experience

Dates

Employer

Position

Description

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Previous Work Experience

Dates

Employer

Position

Description

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Supervision or Consultation (current and previous)(Required)

Supervisor/Consultant

Dates

Frequency

Please click the plus sign at the end of the row to add up to 1 additional lines.

Personal Analysis or Therapy (Your therapist will not be contacted.)

Therapist or Analyst

Session Frequency

Dates: From/To

Approximate Total # of Sessions

Please click the plus sign at the end of the row to add up to an additional line.

Describe any special circumstances that might affect or complicate your participation in this program:(Required)

What are your goals in undertaking this program?(Required)

Describe your experience doing psychotherapy or counseling. Please include specific information about the type of treatment offered, the number of patients the frequency and length of sessions. This may be included as an additional attachment to the application.(Required)

Signature(Required)