Application First Name Last Name Email Address Phone Number License Type License Number Degree Type Highest Degree Completed Was Your Masters Program CACREP Accredited? YesNo Field of Speciality Years of Mental Health Experience Years of Supervision Experience Will You Require Distance Learning Technology to Participate? YesNo Do You Agree to be a part of Research Related to this Academy? If yes, additional documentation will be provided to you at the first meeting. YesNo Why you would like to join this Academy? What do you hope to gain from the experience?