Supervision Form – Heart Work

Professional Supervision - Contact Information

First Name *

Last Name *

Preferred Name *

Email *

Phone *

Address *

Date of Birth *

Age *

Preferred Pronouns *Her/SheHe/HimThey/ThemChoose your own

Choose your own pronoun

Do you have any disabilities? *YesNo

Please let us know if you have any special needs *

What is your preferred method of engaging in Supervision? *Face to FaceZoom video callTelephone call

Preferred method of communication in relation to booking/cancelling appointments? *Text message to mobile phoneBy email

Is there anyone you would like me to contact in an emergency?

Full Name *

Relationship *

Phone No *

What is the name of your current Service, Organization or Business and location (suburb)? *

Position Role title *

Length of time held *

Other roles previously held *

Training and Qualification Summary:

Health Matters

Are there any past or current physical health issues that you have? *Allergies / food sensitivitiesCancerAsthmaChronic painHeart conditionEpilepsyDifficulty sleepingI am generally well and have no significant physical health issuesOther (Please provide further details):

Are there any other needs you might have? *Kinship and CulturalPrevious work related traumaMental health concernsCareer responsibilitiesNone/do not wish to discloseOther (please provide details):

Your prior experience, understanding and hopes for Supervision.

Is this your first time accessing Supervision? *YesNo

Please give details of your prior experience of supervision:

In approximately 25 words please give a summary of your understanding of the purpose of supervision? *0 / 25

How important are "embodied practices" in your work? *Eg. Staying connected with your bodily responses, noticing what supports you physically/emotionally, breathing, physical movement and or play in your work? (Please circle on the scale below)UnimportantNot sureImportant

Comments (optional):

How do you care for yourself in your work and outside of work? *

Do you have any other interests, needs or resources that may be helpful in your work right now? *

Do you consent to the information in 'Part 3' (only) being used for research?Information used for Research purposes will be de-identified and anonymous.YesNo

Do you have any other questions?

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Professional Supervision - Contact Information

Is there anyone you would like me to contact in an emergency?

Health Matters

Your prior experience, understanding and hopes for Supervision.

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