SECTION 86:16-7-6. Additional forms

(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.

[Source: Transferred from 310:400-7-5 by Laws 2013, c. 229, § 3(F), eff 11-1-13 (see Editor’s Note at beginning of this Chapter)]