Contact Form

Your reason for contact:

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Name

First Name

Last Name

Date of Birth

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Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

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Health Insurance Carrier (Vida Counseling is credentialed with most BCBS plans):

Do you have a strong preference for in-person or virtual sessions?

How did you find Vida Counseling? (Please provide the specific name of who referred you)

Message *

Our Office

6512 Six Forks Road. Suite 403B.
Raleigh, NC, 27615
United States

919-591-0800

*Please note that e-mail is our preferred method of communication. You can reach us at:

info@vidacounseling.org

Professional Supervision or Consultation Request Form

Your reason for contact:

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Name

First Name

Last Name

Email Address

Phone

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How did you find Dr. Portela as a supervisor?

What license do you have? Also, is this clinical supervision for you to obtain your license or a certification? If yes, please specify (LCMHC, RPT).

Do you currently have a clinical supervisor? If yes, who?

How often were you hoping to have supervision?

Dr. Portela prefers to have dyadic or group supervision whenever possible. Is this something you would be interested in?

Where do you work and how many hours per week? Is clinical supervision required for your job?

Where did you obtain your counseling degree? Is the program CACREP accredited?

What is your area of focus or clinical expertise? (Play therapy, EMDR, children, teens, adults, etc.)

Our Office

6512 Six Forks Road. Suite 403B.
Raleigh, NC, 27615
United States

919-591-0800

*Please note that e-mail is our preferred method of communication. You can reach us at:

info@vidacounseling.org

Request a Recommendation Letter from Dr.Portela

Name

First Name

Last Name

Email

University you are currently applying to:

Program you are applying to:

Cumulative GPA

List of courses if you've take with Dr. Portela and grade received:

Purpose of the Letter (e.g., scholarship application, graduate school admission, internship, job):

Deadline for Submission:

Specific Requirements or Prompts for the Letter:

Who should this letter be addressed to?

Where should we submit this letter? Please provide a URL.

What are your strengths related to the purpose of your recommendation letter?

What makes you a good candidate for this position or program that you are applying to?

What are your strengths/superpowers?

When did you meet Dr. Portela? How long have you known Dr. Portela?

Would you like to sharing anything else?