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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 21. Licensed Behavioral Practitioners |
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Subchapter 5. Forms |
SECTION 86:21-5-2. 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 Document of Recommendation requires the following:(1) Identifying information of applicant;(2) Scale of performance rating personal character and professional skills;(3) Circumstances and time period rater has known applicant;(4) Space for rater's comments;(5) Identifying information of rater.(d) The Statement of Professional Disclosure is composed of alternative forms depending on the status of the applicant, as follows.(1) The LBP Candidate's Statement of Professional Disclosure requires the following:(A) Explanation of LBP Candidate's responsibilities;(B) Name and contact information for person who will be responsible for the client's records in the event of the LBP Candidate's infirmity or death;(C) Supervisor's identifying information;(D) Address and phone number of the Department; and,(E) Signatures of client and LBP Candidate.(2) The LBP's Statement of Professional Disclosure requires the following:(A) Explanation of the LBP's responsibilities;(B) Name and contact information for person who will be responsible for the client's records in the event of the LBP's infirmity or death;(C) Address and phone number of the Department; and,(D) Signatures of client and LBP.(e) The Supervision Agreement requires the following:(1) Statement of agreement to fulfill Subchapter 15 and consequences of violation; and(2) Identifying information and signatures of supervisee and supervisor.(f) The On-Site Supervisor Verification Form requires the following identifying information:(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.(g) 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.(h) The Continuing Education Roster requires the following:(1) LBP's name and license number;(2) Total number of hours accrued and LBP's signature and signature date of licensee;(3) Listing of workshops, sponsor, content and date of continuing education experience.(i) The Licensure Verification Request Form requires the following information:(1) Name of licensee;(2) Licensee license number; and(3) Licensee license type.(j) 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.(k) 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.(l) 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.