SECTION 86:11-7-2. Application materials and forms

(a)   Each application shall include the following documents:

(1)   Application form,

(2)   Official transcript, mailed from the university or college,

(3)   Three (3) Document of recommendation forms,

(4)   Practicum documentation form,

(5)   Two (2) classifiable sets of fingerprints, and

(6)   Fees.

(b)   The Application Form requires the following:

(1)   Identifying information;

(2)   Possession of other credentials;

(3)   Previous misconduct;

(4)   Education;

(5)   References; and

(6)   Proposed professional practice.

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

(1)   Identifying information; and

(2)   Time, place, location of practicum.

(d)   The Document of Recommendation requires the following:

(1)   Identifying information;

(2)   Ratings of ethical and professional characteristics; and

(3)   Circumstances and time period submitter has known applicant.

(e)   The Statement of Professional Disclosure requires the following:

(1)   Statement providing for the applicant's disclosure of professional standing; and

(2)   Statement providing for making contact with OSDH for further information.

(f)   The Supervision Agreement requires identifying information of supervisee and supervisor.

(g)   The On-Site Supervisor Verification Form requires identifying information as follows:

(1)   Name of applicant;

(2)   Place of employment;

(3)   On-Site Supervisor information;

(4)   A reproduction of the regulation regarding supervision accrued in a private setting.

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

(1)   Name of licensee;

(2)   Licensee license number; and

(3)   Licensee license type.

(i)   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.

(j)   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.

(k)   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.

(l)   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)   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.

(m)   The Continuing Education Rosters for LPC Approved Supervisors require 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.

[Source: Transferred from 310:405-7-2 by Laws 2013, c. 229, § 3(F), eff 11-1-13 (see Editor’s Note at beginning of this Chapter)]