Observation Form

Observation Intake Form

The Brookline Center invites Boston-area clinicians to observe and learn from our most seasoned group therapists in this enriching professional development series.

Name*
First Last
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
What is/are the clinical setting(s) where you work? If you're a student, what graduate program are you enrolled in and where?*
How many years have you been practicing? If you're a student, how many years of your program have you completed?*
What professional license(s) do you hold?*
Do you currently work at the Brookline Center or have you been offered a training position at the Center?*
Which Observation Group would you observe?*
Questions
What date would you like to begin the observation group program? Participants are welcome to select any date they like, but start dates must be confirmed before observation can begin.*
Date Format: MM slash DD slash YYYY
Are you currently an NSGP member?*
- Yes
- No
Payment Information
Checks: Please address checks to the Brookline Center for Community Mental Health. In the memo section please write Observation Group – Observer. Checks can be mailed to 41 Garrison Road, Brookline, MA 02445.
Credit Card: To pay by credit card, please call the admin office at (617) 277-8107 and ask to pay for the Observation Group.
After submitting an application, the adult group program manager will be in touch with you to confirm your identity, credentials, and possible start date for observation. Please know that remote observers will need to provide photo confirmation of their identity (e.g., photo of driver's license) and current professional license (e.g., photo of licensing card).
Comments
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Observation Intake Form

Questions

Payment Information