Interested in Supervision? Request for Supervision Form Step 1 of 4 25% Please complete this form if you are interested in supervision towards earning/maintaining your credential in behavior analysis. I am a BCBA, QBA, and IBA who is licensed in Alabama, Maryland, and Virginia. Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Email(Required) Which board are you seeking a credentialed with?(Required) Behavior Analyst Certification Board International Behavior Analysis Organization Qualified Applied Behavior Analysis Credentialing Board Where are you in your coursework towards becoming a behavior analyst?(Required) I haven’t started yet I’m in the midst of my coursework I have completed my coursework Do you currently have errors and omissions (malpractice) insurance that covers the practice of applied behavior analysis?(Required)NoYesHave you taken a coursework in human trafficking?(Required)NoYesHave you taken coursework in cultural issues?(Required)NoYesHave you taken coursework in LGBTQIA+ health, diversity & inclusion?(Required)NoYesHave you taken coursework in ethics?(Required)NoYesHave you taken coursework in supervision?(Required)NoYes What age groups do you work with?(Required) 0 – 5 6 – 10 11 – 13 14 – 18 19 – 21 22 – 35 36 – 55 55+ None What diagnoses (if any) do you have experience with?(Required) What diagnoses (if any) do you want to gain experience with?(Required) What areas of practice are you interested in?(Required) Animal training Autism & other developmental disabilities Brain injury rehabilitation Clinical behavior analysis Criminal Justice Education Environmental sustainability Gerontology Health and fitness Organization behavior management Sports psychology Sex ABA Substance use disorders Parenting Pediatrics Prevention and behavioral intervention of child maltreatment Public Health Other Not sure? Select “other” and let us know below. If you would like to look at some information that may help, the Association for Behavior Analysis International has special interest groups that combine ABA with other areas. Visit them at https://www.abainternational.org/constituents/special-interests/special-interest-groups.aspxIf you selected "other" above, please note your area(s) of interest here: Have you completed supervision hours with another supervisor?(Required)–NoYesIf you have completed hours with another supervisor, have you/do you plan to continue working with the other supervisor as well?–NoYesIf you have completed hours with another supervisor, how many RESTRICTED hours do you have?If you have completed hours with another supervisor, how many UNRESTRICTED hours do you have?If you have completed hours with another supervisor, do you have all monthly forms from the other supervisor, and/or your form for the conclusion of that supervision.–NoYesWhat questions do you have?NOTICE: The current fees associated with supervision for the credentials related to the BACB, IBAO, or QABA Board are $100 per hour. This fee is to be paid to Breakthrough Developmental Services, LLC and not to the person providing your supervision. No discounts for this service are available. The “Supervisory Period” is set by the board as 1-month of time. To make this easier, we utilize a calendar month. The supervisor and the supervisee will need to have 4 to 6 Supervisor-Trainee contacts each month based on the type of fieldwork you are completing for the month. For most boards, at least 5% of your hours need to be supervised per supervision period. You are free to meet remotely, or in person. Additionally, the Supervisor will need to observe you working directly with patients/clients in some situations. This time counts into your supervised hours for each period. Please speak with the supervisor directly to determine your exact schedule and more information concerning this. AUTHORIZATION: By submitting this form, you give Breakthrough Developmental Services or our representatives permission to contact you. Submission of this form is not a contract and does not obligate you to begin supervision with Breakthrough Developmental Services. Δ
