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Oklahoma Administrative Code (Last Updated: March 11, 2021) |
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TITLE 86. State Board of Behavioral Health Licensure |
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Chapter 20. Licensed Behavioral Practitioners |
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Subchapter 3. Forms |
SECTION 86:20-3-2. Description of forms
Latest version.
- (1) Identifying information of applicant;(2) Possession of other credentials;(3) Previous misconduct;(4) Education;(5) References; and(6) Proposed professional Practice.(b) The Internship/Practicum Documentation Form requires the following:(1) Identifying information of applicant;(2) Place, time, duration and nature of supervised experience;(3) School arranging supervision and name of supervisor; and,(4) Signature and title of supervisor.(c) 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 LBP Supervisor;(7) Name of Approved LBP Supervisor's place of employment;(8) LBP Approved Supervisor's contact information;(9) Signature of LBP 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.(d) The Evaluation of Supervised Experience Form requires the following:(1) Names of supervisee and supervisor;(2) Name and location of supervision site;(3) Duration of work experience and supervision;(4) Types of professional activities and clients seen;(5) Rating of quality of professional activities;(6) Supervisor and supervisee comments; and(7) Signatures of supervisee and supervisor.(e) The Continuing Education Roster requires the following:(1) Licensee's name and license number;(2) Total number of hours accrued and Licensee's signature and signature date of licensee;(3) Listing of workshops, sponsor, content and date of continuing education experience.(f) The Licensure Verification Request Form requires the following information:(1) Name of licensee;(2) Licensee license number; and(3) Licensee license type.(g) 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;(11) Signature and identifying information of person verifying from out-of-state.(h) The Mailing Addresses Request/Order Form requires the following information:(1) Type of licensure list requested;(2) Format requested;(3) Identifying information of person making request.(i) 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;(6) Dates of inactivation and reactivation of license.(j) 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.