SECTION 86:15-5-4. Additional forms


Latest version.
  • (a)   Licensure Verification Request Form - name of licensee; licensee license number; and licensee license type.
    (b)   Out-of-State License Verification Form - identifying information; type of credential held in other state; license number; issue and expiration date of license; current standing of license; past complaints or sanctions; exam information; supervision information; graduate education; internship documentation; signature and identifying information of person verifying from out-of-state.
    (c)   Mailing Addresses Request/Order Form - type of licensure list requested; format requested; identifying information of person making request.
    (d)   Licensure Reactivation Request Form - licensure type, identifying information; employment information; graduate education; license type and number; dates of inactivation and reactivation of license.
    (e)   LMFT Continuing Education Approval Application Form - name of workshop; program context; program knowledge area; name of presenter; presenter qualifications; date of presentation; number of hours requested; sponsoring agency; name of contact; phone number of contact; signature and signature date of contact; program content in relation to mental health ethics; program content in relation to therapy supervision; number of hours requested for mental health ethics; number of hour requested for therapy supervision.
    (f)   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 159, eff 4-23-14 (emergency); Added at 32 Ok Reg 1569, eff 9-11-15]