LPC - Professional Licensing Boards

MENTAL HEALTH PROFESSIONS LICENSING BOARD
2001 Capitol Ave, Room 104
Cheyenne WY 82002
LICENSED PROFESSIONAL COUNSELOR
Renewal Application Instructions
Requirements stated in these instructions are condensed from the Rules and Regulations. Please refer to the
Rules and Regulations and read these instructions thoroughly before completing the renewal application.
-All fees are non-refundable.
GENERAL INFORMATION
-The complete renewal application must be POST MARKED on or prior to your expiration date (or on
the next business day in cases when the expiration date falls on a weekend or holiday) in order for
your license to remain current. Any renewal application postmarked after the appropriate date will be
returned and your license will become null and void.
-A complete renewal application consists of the Licensed Professional Counselor Renewal
Application form and the renewal fee made payable to the “State of Wyoming”. License renewal fee is
$125.00. If you renew more than one license during the same two (2) year period, remit $75.00 for
each additional license.
-Type or print all information legibly. Your renewal application will not be accepted and the information
provided will not be reviewed unless all areas of this form are complete. Incomplete applications will
be returned. If more space is needed, attach an additional sheet of paper. Across the top of the
additional sheet print your name and license number.
-If you fail to renew but wish to be licensed in Wyoming, you will be required to re-apply and meet
current standards. THERE IS NO GRACE PERIOD!
-If you have retired from active practice, you may request that your license be placed on “Retired”
status. Please refer to the Rules and Regulations, Chapter 14 for specific information.
-If you will not be renewing your license to practice in the State of Wyoming, please inform the Board
in writing at the above address.
-Failure to receive notice from the Board does not excuse you from the requirement for renewal.
Applications for renewal will not be accepted more than one hundred twenty (120) days prior to the
expiration date.
-You must register with the Board, in writing, any change in your legal name, home and business
mailing address and telephone number(s) within thirty (30) days of the change.
Revised 8/2013
Guidelines for the Documentation of Continuing Education
All persons must complete forty-five (45) clock hours of acceptable continuing education every two (2)
years as a condition of renewal. In addition each person must provide verification that at least three
(3) continuing education activity hours completed during the renewal period were in professional
ethics. List your continuing education activities in the tables provided. Do not write “See Attached”
and then list your continuing education activities on a separate page. You must provide as much

information on the renewal form itself as space allows. If additional space is needed, you may attach
a continuance.
♦ Clock hours are the actual number of hours (contact hours) during which instruction was given. A
contact hour shall consist of not less than fifty (50) minutes of actual instruction or presentation.
(A 50 minute presentation may be reported as 1 hour.) For academic courses, one (1) semester
credit equals fifteen (15) hours.
♦ Only those hours acquired during the renewal period will be considered.
♦ Continuing education activities should have significant intellectual or practical content and the
primary objective should be to increase the participant's competence as a professional counselor.
Each activity should be an organized program of learning dealing with matters directly related to
the practice, professional responsibility or ethical obligations of a professional counselor.
Presenters of activities should be experts in the mental health field and of at least master's degree
level in education. The scope of practice for a professional counselor as defined in the Rules and
Regulations may be used as a basis of what knowledge and skills are acceptable to the Board as
continuing education activities.
♦ You are not required to submit proof of attendance with your renewal application. You must
maintain copies of any certificates of attendance, letters certifying attendance, transcripts, or any
official documents which serve as proof of participation or attendance for at least two (2) years
from the date submitted for renewal, and present them if selected for audit.
♦ It is your responsibility to obtain the necessary documentation from the continuing education
activity sponsor. You should require that the sponsor keep an accurate long-term record of the
activity, those in attendance, contact hours, credentials of the presenters and brochures
describing the continuing education activity for retrieval of documentation.
♦ There is no process in place to pre-approve any continuing education activity. As a guideline,
sponsoring agencies should use the scope of practice for each discipline in designing continuing
education activity and providing contact hours to licensees and certificate holders of this Board.
The scope of practice information is in the Rules and Regulations.
NOTIFICATION
When the Board has reviewed and approved your renewal application, you will receive a confirmation
letter, renewal fee receipt, and two (2) pocket cards. One card is placed over the expiration date on
your wall certificate. The other should be carried with you for identification purposes.
Thank you for taking the time to review these procedures. Please feel free to contact Emily
Cronbaugh at 307-777-3628, WyoMHPLB@wyo.gov or Michelle Lamorie at 307-777-7788,
WyoMHPLB@wyo.gov if you have any questions about the renewal process.
Revised 8/2013

MENTAL HEALTH PROFESSIONS LICENSING BOARD
2001 Capitol Ave, Room 104
Cheyenne, WY 82002
(307) 777-3628
LICENSED PROFESSIONAL COUNSELOR
Renewal Application
Your renewal application with the appropriate fee must be POSTMARKED by your license expiration date in order to be considered.
You must submit a complete license renewal application and fee for each license you hold.
Fee: License- $125.00 for the first license, $75.00 for each additional license
MAKE CHECKS PAYABLE TO “STATE OF WYOMING”
Please read the renewal application instructions thoroughly before completing this form.
THERE IS NO GRACE PERIOD
1. Name:
Residence Address And Telephone
2. Address:
City: State: Zip:
Telephone:
Business Address And Telephone
3. Business:
Address:
City: State: Zip:
Telephone:
4. Preferred Address for Correspondence: Residence Business
5. E-mail address:
Please provide an e-mail address that you check regularly. If there are any questions or issues regarding your application,
the Board staff will communicate with you at this address.
6. Each licensee is required to complete a minimum of three (3) contact hours of professional ethics continuing education during the two (2) year
renewal period. These three (3) hours are part of the forty-five (45) hour requirement. Itemize your professional ethics continuing education
activity here.
A
B
C
DATE(S)
COURSE/ACTIVITY
PROGRAM
SPONSOR
CONTACT
HOURS
TOTAL CONTACT HOURS IN ETHICS SUBMITTED
Revised 8/2013

7.
A
Itemize your remaining continuing education activities in this table. Limit your entries to those necessary to meet the forty-five (45) contact
hour requirement. List only one (1) program per line. If more space is needed, attach a page with a list of the additional activities in the same
format as the table provided.
DATE(S)
COURSE/ACTIVITY
PROGRAM
SPONSOR
CONTACT
HOURS
B
C
D
E
F
G
TOTAL CONTACT HOURS SUBMITTED INCLUDING ETHICS
8. During the last three (3) years, has any state rejected your application for licensure and/or certification Yes No
9. During the last three (3) years, has any state revoked, suspended, refused to renew, or otherwise restricted your license
and/or certification
10. During the last three (3) years, have you voluntarily surrendered your license and/or certification in order to avoid
disciplinary action by a regulatory agency
11. During the last three (3) years, have you been sanctioned by a professional association Yes No
12. During the last three (3) years, have you been convicted of a misdemeanor involving moral turpitude (A plea of no
contest shall create a presumption of guilt to the underlying criminal charges.)
13. During the last three (3) years, have you been convicted of a felony (A plea of no contest shall create a presumption of
guilt to the underlying criminal charges.)
14. Are you addicted to the use of alcohol, any narcotic, or other drugs having similar effects to an extent or in a manner
dangerous to yourself, any other person or the public, or to an extent that use impairs your ability to provide services
with safety to the public
15. Has a court of competent jurisdiction ever judged you incompetent Yes No
16. During the last three (3) years, have you violated and been convicted of a charge under the Wyoming Controlled
Substances Act
If you answered "Yes" to any of the previous questions you are required to provide documentation relative to your "Yes" answer in order for your
renewal application to be considered. Documentation shall include, but not be limited to, certified copies of court records, letters of sanction, state
board disciplinary action documents, etc. Attach supporting documents to this application.
WARNING
Making a false statement or giving a false answer to any question on this form is a felony punishable by imprisonment for not more than two (2)
years, a fine of not more than two thousand dollars ($2,000.00), or both. (W.S. § 6-5-303.)
AFFIDAVIT
I am the person making the foregoing statements and that they are made in good faith and are true in every respect. I have read, understand, and
agree to abide by the Rules and Regulations promulgated by the Mental Health Professions Licensing Board, and W.S. § 33-38-101 through 113.
I have satisfied the Continuing Education requirement for the renewal of my license. I understand that I may be selected for audit of my Continuing
Education and may be subject to disciplinary action should I misrepresent my compliance.
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
SIGNATURE OF APPLICANT
DATE
Revised 8/2013