SECTION 86:10-7-2. Application materials and forms

(a)   Each application shall include the following documents:

(1)   Application form,

(2)   Official transcript(s),

(3)   Internship/Practicum Documentation Form,

(4)   Completed criminal background check, and

(5)   Fees.

(b)   The Application Form requires the following:

(1)   Identifying information;

(2)   Possession of other credentials;

(3)   Previous misconduct;

(4)   Education; and

(5)   Proposed professional practice.

(c)   The Internship/Practicum Documentation form requires the following:

(1)   Identifying information; and

(2)   Time, place, location of practicum.

(d)   The Supervision Agreement requires identifying information of supervisee and supervisor as follows:

(1)   Name of candidate;

(2)   Name of candidate's place of employment;

(3)   Location supervised experience hours are being accrued;

(4)   Candidate's contact information;

(5)   Signature of Candidate;

(6)   Name of Approved LPC Supervisor;

(7)   Name of Approved LPC Supervisor's place of employment;

(8)   LPC Approved Supervisor's contact information;

(9)   Signature of LPC Approved Supervisor;

(10)   Name of On-Site Supervisor;

(11)   On-Site Supervisor's licensure information;

(12)   Name of On-Site Supervisor's place of employment;

(13)   On-Site Supervisor's contact information;

(14)   Signature of On-Site Supervisor.

(e)   The Licensure Verification Request Form requires the following information:

(1)   Name of licensee;

(2)   Licensee license number; and

(3)   Licensee license type.

(f)   The Out-of-State Licensure Verification Form requires the following information:

(1)   Identifying information;

(2)   Type of credential held in other state;

(3)   License number;

(4)   Issue and expiration date of license;

(5)   Current standing of license;

(6)   Past complaints or sanctions;

(7)   Exam information;

(8)   Supervision information;

(9)   Graduate education;

(10)   Internship documentation; and

(11)   Signature and identifying information of person verifying from out-of-state.

(g)   The Mailing Addresses Request/Order Form requires the following information:

(1)   Type of licensure list requested;

(2)   Format requested; and

(3)   Identifying information of person making request.

(h)   The Licensure Reactivation Request Form requires the following information:

(1)   Licensure type;

(2)   Identifying information;

(3)   Employment information;

(4)   Graduate education;

(5)   License type and number; and

(6)   Dates of inactivation and reactivation of license.

(i)   The LPC Continuing Education Approval Application Form requires the following information:

(1)   name of workshop;

(2)   program context;

(3)   program knowledge area;

(4)   name of presenter;

(5)   presenter qualifications;

(6)   date of presentation;

(7)   number of hours requested;

(8)   sponsoring agency;

(9)   name of contact;

(10)   phone number of contact;

(11)   signature and signature date of contact;

(12)   program content in relation to counseling ethics;

(13)   program content in relation to counseling supervision;

(14)   number of hours requested for counseling ethics; and

(15)   number of hour requested for counseling supervision.

(j)   The Continuing Education Rosters for LPC Approved Supervisors requires the following information:

(1)   name of licensee;

(2)   signature and signature date of licensee;

(3)   total clock hours of workshop(s);

(4)   name of counseling supervision workshop;

(5)   sponsoring agency of workshop(s); and

(6)   date of workshop(s), and number of hours of each workshop.

(k)   The Termination of Supervision Agreement requires the following information:

(1)   name of candidate;

(2)   current place of employment of candidate;

(3)   address of current place of employment of candidate;

(4)   phone number of candidate;

(5)   email address of candidate;

(6)   signature and signature date of candidate, (if available);

(7)   name of supervisor;

(8)   license number of supervisor;

(9)   current place of employment of supervisor;

(10)   phone number of supervisor;

(11)   email address of supervisor;

(12)   signature and signature date of supervisor, (if available); and

(13)   effective date of termination of supervision agreement.

[Source: Added at 32 Ok Reg 139, eff 4-23-14 (emergency); Added at 32 Ok Reg 1547, eff 9-11-15; Amended at 36 Ok Reg 492, eff 7-25-19]