Clinical Supervisor Registration

Important Note

NEW MEMBERS: There is no need to check the accuracy of your profile.

CURRENT MEMBERS: Check your profile page by visiting "My Account" to make sure your information is correct for publishing publicly. Once you have done this, return here.

There are 2 mandatory steps required before completing this registration form. Please note that you must be a current WMHCA member with a public profile to be listed in the registry.

Download this form and sign and complete the form.
Complete the online form below and upload the signed form into the field below, or mail the completed form to:

WMHCA
11410 NE 124th St.
Kirkland, WA 98034

Clinical Supervisors must meet requirements by the state of Washington, REVIEW REQUIREMENTS HERE

Date
MM slash DD slash YYYY
Name
First Last
Email*
License Number*
Upload the completed "Approved Supervisor" form here.*
Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 256 MB.

Supervisor Registration

Important Note

There are 2 mandatory steps required before completing this registration form. Please note that you must be a current WMHCA member with a public profile to be listed in the registry.

Become a Supervisor