MFT Student Location and License Confirmation

MFT Student Location and License Confirmation
Student Name*

First NameLast Name
Student's Preferred Email*
example@example.com
Is this the first time filling out this form?*

YesNo
If you have filled out this form before, please select reason for completing this form again (you can select multiple fields as applicable):

I am vetting a new site and supervisor in Experiential Learning Cloud (ELC; formerly known as Tevera), and need to complete this form again, but nothing with my location or licensure goals have changedI am moving statesMy future goals have changedOther
Student Current Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Current Physical Location Country?*
Date

MonthDayYear
Date
Academic and Finance Advisor's Email*
Please input advisingservices@nu.edu
Your Site's Name:*
State You Plan to be Licensed In*
State Intended Site is Located In*
State Intended Supervisor is Located In*
State Intended Supervisor is LICENSED In*
If outside of US please indicate:*
I understand that it is my responsibility to notify my advisor and the training team if there are any changes to the above information once I submit this form.*

I acknowledge
I understand that if I change my intended state of licensure while active in clinical training, I may need to complete additional training requirements or program credits.*

I acknowledge
Signature*

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