LICENSURE REQUIREMENTS FOR PROFESSIONAL COUNSELOR

LICENSURE REQUIREMENTS FOR PROFESSIONAL COUNSELOR 

Effective September 29, 2010 

These requirements are summarized from the Board’s Rules and Regulations. Please review Chapter 11 

of the Rules at http://plboards.state.wy.us/mentalhealth/rulesregs.asp for complete details. 

General: 

Education: 

Be of a majority age; and 

Have no felony convictions, and no misdemeanor convictions involving moral turpitude, although 

the Board may grant exceptions to this requirement if consistent with the public interest; and 

Are a legal inhabitant of the United States; and 

Demonstrate integrity, professionalism and character in professional counseling through three (3) 

professional recommendations which attest to applicants’ abilities and professional performance. 

Complete of a graduate degree program in counseling from a Council for Accreditation of Counseling and 

Related Educational Programs (CACREP) or Council on Rehabilitation Education (CORE) accredited 

program in counseling. 

Complete a graduate counselor program that meets the following criteria: 

OR 

The graduate degree program, and any applicable additional graduate level course work, was 

completed at an educational institution accredited by one of the regional or national institutional 

accrediting bodies recognized by the Council for Higher Education Accreditation (CHEA). 

The program was substantially similar in content as required by CACREP including instructor 

qualifications, clinical supervision and course work. 

A minimum of seventy-two (72) quarter hours or forty-eight (48) semester hours of graduate level 

course work is required. 

The official transcripts, course prefixes, and course descriptions clearly identify the educational 

program as preparing persons to be professional counselors. 

Course work was completed in a master’s or doctoral program or subsequent graduate level 

course work.

Course work was completed in each of the core areas defined herein: 

Practicums, Internships or Field Experience under clinical supervision. 

Human Growth and Development- studies that provide an understanding of the nature 

and needs of individuals at all developmental levels, including all of the following: 

• Theories of individual and family development and transitions across the life-span; 

• Theories of learning and personality development; 

• Human behavior including an understanding of developmental crises, disability, 

exceptional behavior, addictive behavior, psychopathology, and situational and 

environmental factors that affect both normal and abnormal behavior; 

• Strategies for facilitating optimum development over the life-span; and 

• Ethical and legal considerations. 

Social and Cultural Diversity- studies that provide an understanding of the cultural context 

of relationships, issues and trends in a multicultural and diverse society related to such 

factors as culture, ethnicity, nationality, age, gender, sexual orientation, mental and 

physical characteristics, education, family values, religious and spiritual values, 

socioeconomic status and unique characteristics of individuals, couples, families, ethnic 

groups, and communities including all of the following: 

• Multicultural and pluralistic trends, including characteristics and concerns between 

and within diverse groups nationally and internationally; 

• Attitudes, beliefs, understandings, and acculturative experiences, including 

specific experiential learning activities; 

• Individual, couple, family, group, and community strategies for working with 

diverse populations and ethnic groups; 

• Counselors’ roles in social justice, advocacy and conflict resolution, cultural selfawareness, 

the nature of biases, prejudices, processes of intentional and 

unintentional oppression and discrimination, and other culturally supported 

behaviors that are detrimental to the growth of the human spirit, mind, or body; 

• Theories of multicultural counseling, theories of identity development, and 

multicultural competencies; and 


Helping Relationships- studies that provide an understanding of counseling and 

consultation processes, including all of the following: 

• Counselor and consultant characteristics and behaviors that influence helping 

processes including age, gender, and ethnic differences, verbal and nonverbal 

behaviors and personal characteristics, orientations, and skills; 

• An understanding of essential interviewing and counseling skills so that the 

student is able to develop a therapeutic relationship, establish appropriate 

counseling goals, design intervention strategies, evaluate client outcome, and 

successfully terminate the counselor-client relationship. Studies will also facilitate

student self-awareness so that the counselor-client relationship is therapeutic and 

the counselor maintains appropriate professional boundaries; 

• Counseling theories that provide the student with a consistent model(s) to 

conceptualize client presentation and select appropriate counseling interventions. 

Student experiences should include an examination of the historical development 

of counseling theories, an exploration of affective, behavioral, and cognitive 

theories, and an opportunity to apply the theoretical material to case studies. 

Students will also be exposed to models of counseling that are consistent with 

current professional research and practice in the field so that they can begin to 

develop a personal model of counseling; 

• A systems perspective that provides an understanding of family and other systems 

theories and major models of family and related interventions. Students will be 

exposed to a rationale for selecting family and other systems theories as 

appropriate modalities for family assessment and counseling; 

• A general framework for understanding and practicing. Student experiences 

should include an examination of the historical development of consultation, an 

exploration of the stages of consultation and the major models of consultation, and 

an opportunity to apply the theoretical material to case presentations. Students 

will begin to develop a personal model of consultation; 

• Integration of technological strategies and applications within counseling and 

consultation processes; and 


Group Work- studies that provide both theoretical and experiential understandings of 

group purpose, development, dynamics, counseling theories, group counseling methods 

and skills, and other group approaches, including all of the following: 

• Principles of group dynamics, including group process components, 

developmental stage theories, group members’ roles and behaviors, and 

therapeutic factors of group work; 

• Group leadership styles and approaches, including characteristics of various types 

of group leaders and leadership styles; 

• Theories of group counseling, including commonalties, distinguishing 

characteristics, and pertinent research and literature; 

• Group counseling methods, including group counselor orientations and behaviors, 

appropriate selection criteria and methods, and methods of evaluation of 

effectiveness; 

• Approaches used for other types of group work, including task groups, psycho 

educational groups, and therapy groups; 

• Professional preparation standards for group leaders; and 


Career Development- studies that provide an understanding of career development and 

related life factors, including all of the following: 

• Career development theories and decision-making models;

• Career, avocational, educational, occupational and labor market information 

resources, visual and print media, computer-based career information systems, 

and other electronic career information systems; 

• Career development program planning, organization, implementation, 

administration, and evaluation; 

• Interrelationships among and between work, family, and other life roles and factors 

including the role of diversity and gender in career development; 

• Career and educational planning, placement, follow-up, and evaluation; 

• Assessment instruments and techniques that are relevant to career planning and 

decision making; 

• Technology-based career development applications and strategies, including 

computer-assisted career guidance and information systems and appropriate 

world-wide web sites; 

• Career counseling processes, techniques, and resources, including those 

applicable to specific populations; and 


Assessment- studies that provide an understanding of individual and group approaches to 

assessment and evaluation, including all of the following: 

• Historical perspectives concerning the nature and meaning of assessment; 

• Basic concepts of standardized and non-standardized testing and other 

assessment techniques including norm-referenced and criterion-referenced 

assessment, environmental assessment, performance assessment, individual and 

group test and inventory methods, behavioral observations, and computermanaged 

and computer-assisted methods; 

• Statistical concepts, including scales of measurement, measures of central 

tendency, indices of variability, shapes and types of distributions, and correlations; 

• Reliability (i.e., theory of measurement error, models of reliability, and the use of 

reliability information); 

• Validity (i.e., evidence of validity, types of validity, and the relationship between 

reliability and validity; 

• Age, gender, sexual orientation, ethnicity, language, disability, culture, spirituality, 

and other factors related to the assessment and evaluation of individuals, groups, 

and specific populations; 

• Strategies for selecting, administering, and interpreting assessment and evaluation 

instruments and techniques in counseling; 

• An understanding of general principles and methods of case conceptualization, 

assessment, and/or diagnoses of mental and emotional status; and 


Research and Program Evaluation- studies that provide an understanding of research 

methods, statistical analysis, needs assessment, and program evaluation, including all of 

the following: 

• The importance of research and opportunities and difficulties in conducting 

research in the counseling profession,

Experience/Supervision: 

• Research methods such as qualitative, quantitative, single-case designs, action 

research, and outcome-based research; 

• Use of technology and statistical methods in conducting research and program 

evaluation, assuming basic computer literacy; 

• Principles, models, and applications of needs assessment, program evaluation, 

and use of findings to effect program modifications; 

• Use of research to improve counseling effectiveness; and 


Professional Orientation and Ethical Practice- studies that provide an understanding of all 

of the following aspects of professional functioning: 

• History and philosophy of the counseling profession, including significant factors 

and events; 

• Professional roles, functions, and relationships with other human service 

providers; 

• Technological competence and computer literacy; 

• Professional organizations, primarily ACA, its divisions, branches, and affiliates, 

including membership benefits, activities, services to members, and current 

emphases; 

• Professional credentialing, including certification, licensure, and accreditation 

practices and standards, and the effects of public policy on these issues; 

• Public and private policy processes, including the role of the professional 

counselor in advocating on behalf of the profession; 

• Advocacy processes needed to address institutional and social barriers that 

impede access, equity, and success for clients; and 

• Ethical standards of ACA and related entities, and applications of ethical and legal 

considerations in professional counseling. 

Complete a minimum of three thousand (3,000) hours of supervised clinical training/work experience in 

professional counseling under the direct supervision of a designated qualified clinical supervisor. 

All three thousand (3,000) hours of supervised clinical training/work experience required shall be 

completed after the award of the master’s degree. Of the three thousand (3,000) hours required, at 

least one thousand two hundred (1,200) hours shall be direct client contact hours. 

A minimum of one hundred (100) post master’s hours of direct, verifiable, individual and/or triadic 

face-to-face clinical supervision with a designated qualified clinical supervisor is required. Group 

supervision is not acceptable towards completion of the face-to-face clinical supervision 

requirement. 

Those persons who are issued a provisional license before January 2, 2011 may also submit experience 

and supervision earned as part of their master’s degree practicum and internship towards meeting the 

experience and supervision requirement, provided the experience is clinical in nature, and the supervisor 

meets the criteria for a Qualified Clinical Supervisor.

Examination: 

The Board will accept: 

The National Board for Certified Counselor’s (NBCC) National Counselor Examination (NCE) or the 

National Clinical Mental Health Examination (NCMHE). 

The Certification Examination administered by the Commission on Rehabilitation Counselor 

Certification (CRCC). 

Other examinations may be approved by the Board on a case by case basis.

APPLICATION INSTRUCTINS 

Licensed Professional Counselor (LPC) by Reciprocity 

Licensure by reciprocity means that you hold a current license for independent clinical practice, in good standing, issued by 

a state regulatory board with legislatively granted authority to regulate the practice of professional counseling. In addition, 

the requirements for licensure in the state where you currently hold a license in good standing are substantially similar to the 

requirements defined in Wyoming Statutes and the Board’s Rules and Regulations. 

Be aware that if you do not meet one of the exemptions provided in W.S. 33-38-103, you MAY NOT provide clinical services 

in Wyoming until you are issued a license by the Board. 

Specific requirements are detailed in the Rules and Regulations. Please review the requirements prior to submitting an 

application. 

GENERAL INFORMATION 

• Application files will be presented to the Application Review Committee (Committee) for consideration when all 

required documentation has been received. 

• The Committee will not review your qualifications without receipt of a formal application and fee. 

• The application fee for a reciprocal license is $350.00. Make checks payable to the “State of Wyoming”. Do not 

send cash. All fees are non-refundable regardless of the outcome. 

• All documents offered in support of the application must be submitted directly to the Committee from the source, not 

forwarded through you. 

DOCUMENTS 

Required Documents: 

• Complete application 

• Appropriate application fee 

• Documentation of legal presence in the U.S. (See attached list A and B) 

• State License/Certification Verification 

• Three (3) professional references 

Additional documents which may be requested: 

• Official transcript(s) of your master’s degree program 

• Self conducted transcript evaluation 

INSTRUCTIONS 

Application 

• The check boxes for Discipline and Method are completed for you. 

• Type or print all information clearly. 

• Items #1-4 need no specific instruction. 

• Items #5 and 6 Current Employer- It is very important that you provide your current employer, and not your 

prospective employer. If you are currently unemployed, please leave this area blank. 

• Item #7 Preferred Mailing Address- If you do not indicate a preference our records will default to your home 

address.

• Item #8 E-mail Address- Provide an e-mail address that you check regularly. We will notify you via e-mail when 

your application form is received. If there are any issues or questions concerning your application, these will be 

communicated to you through e-mail. 

• Item #9 Registrations- Provide complete information regarding any licenses or certifications you now hold or have 

ever held in any profession. 

• Item #10 Education- Make sure that you have reviewed the education criteria for licensure in Professional 

Counseling. You may be required to provide an official transcript and a transcript evaluation in support of your 

application. 

• Item #11 Reference- Provide the requested information for the 3 persons who will be submitting a Professional 

Reference form on your behalf. These forms must be provided directly to the Board from the reference. The Board 

cannot accept these references from you or through your hands in any way. 

• Item #12 Professional Credentials- Provide information regarding your professional certifications such as NBCC, 

ACA, etc. This information may be valuable to the Committee particularly for reciprocal applicants. 

• Item #13 Work History- Start with your most recent employment/experience and work backward in time. Account 

for all gaps in time such as periods of unemployment or education. 

• Items #14-23- Provide a written explanation for each of your “Yes” answers. Make sure that your name appears on 

additional documents. Include documentation such as certified copies of court records, state disciplinary action 

documents, letters of sanction from professional associations, etc. 

• Read the Warning, Agreement and Affidavit. Remember, you are stating that you have read, and agree to abide 

by, the rules and regulations. The rules are available on the Board’s web page at 

http://plboards.state.wy.us/mentalhealth. Read them. Sign and date the application. Please sign in blue ink. Mail 

the original application, appropriate fee and proof of legal presence to the Board. 

Documentation of Legal Presence in the U.S. 

• U.S. Code Title 8, Chapter 14, Section 1621 requires that all licensing agencies collect proof of legal presence in 

the United States. Generally applicants find it easiest to provide a copy of a state issued birth certificate, a copy of 

a passport, or a copy of a social security card. 

• Originals will not be returned. 

• If you cannot provide any of these documents, please refer to the enclosed List A and B for other acceptable 

documents. 

State License/Certification Verification 

• Verification is required if you hold a license as a professional counselor for independent clinical practice, in good 

standing, issued by a state regulatory board with legislatively granted authority to regulate the practice of 

professional counseling. 

• Complete only the Applicant section of the form and send it to the state licensing board(s) listed under item #9 on 

your application. We recommend that you contact the licensing board before sending them the form. Most 

licensing boards charge a fee to verify licenses. 

• Do not complete this form yourself or send this form to the Committee with your application. It must be sent directly 

to the Committee from the state licensing board where you hold a qualifying license. 

Professional Reference 

• You must request Professional References three (3) professionals with at least six (6) months of direct knowledge 

of your abilities and professional performance in professional counseling. 

• Professional References must be submitted on the forms provided by the Board. The reference may e-mail the 

form to WyoMHPLB@wyo.gov, fax it to (307) 777-3508, or mail it to the address provided in these instructions. 

• Professional References must be sent directly to the Committee from the reference and not forwarded through you. 

• Professional References must have been written within six (6) months of your application date. 

• Professional References will not be accepted from natural or legal relatives.

Official Transcript 

• If requested by the Application Review Committee, request that the college or university listed on your application 

under item #10, send an official transcript of your master's degree program directly to the Board office. The school 

may e-mail the transcript to WyoMHPLB@wyo.gov, fax it to (307) 777-3508, or mail it to the address provided in 

these instructions. 

• The Committee will not accept transcripts issued to you or received directly from you unless they are in a sealed 

envelope stamped by the registrar across the seal. 

• Make sure that your college or university is regionally accredited. By this we mean accredited by one of the 

regional or national institutional accrediting bodies recognized by the Council for Higher Education Accreditation 

(CHEA). You can verify your school’s accreditation online at http://www.chea.org/search/default.asp. 

Transcript Evaluation 

• If requested by the Application Review Committee, you must provide a completed Transcript Evaluation which 

details your qualifications for the LPC to the Committee. All courses listed must appear on an official transcript. If 

you are using undergraduate coursework to meet any of the educational criteria, request those official transcripts as 

instructed above. 

PROCEDURE 

You will receive an e-mail acknowledging that your application form, fee, and proof of legal presence have been received. 

You may inquire about your application status by e-mailing to WyoMHPLB@wyo.gov. Please limit your inquiries to no more 

than twice per week. When all required supportive documents have been received, the Application Review Committee will 

evaluate your application. You will be notified of the outcome. 

Inquiries regarding these application procedures and application status may be directed to WyoMHPLB@wyo.gov 

Mental Health Professions Licensing Board 

2001 Capitol Ave, Room 104 

Cheyenne, WY 82002 

Web Site: http://plboards.state.wy.us/mentalhealth

LIST A 

ACCEPTABLE DOCUMENTS TO ESTABLISH U.S. CITIZENSHIP 

A person who is a citizen of the United States as evidenced by one of the following: 

1. A copy of a birth certificate issued in or by a city, county, state, or other governmental entity within the United States or its outlying 

possessions. 

2. A U.S. Certificate of Birth Abroad (FS-545, DS-135) or a Report of Birth Abroad of a U.S. Citizen (FS-240). 

3. A birth certificate or passport issued from: 

A. Puerto Rico, on or after January 13, 1941; 

B. Guam, on or after April 10, 1898; 

C. U.S. Virgin Islands, on or after February 25, 1927; 

D. Northern Mariana Islands, after November 4, 1986; 

E. American Samoa; 

F. Swain’s Island; or 

G. District of Columbia. 

4. A U.S. passport (expired or unexpired). 

5. Certificate of Naturalization (N-550, N-57, N-578). 

6. Certificate of Citizenship (N-560, N-561, N-645). 

7. U.S. Citizen Identification Card (I-179, I-197). 

8. An individual Fee Register Receipt (Form G-711) that shows that the person has filed an application for a New Naturalization or 

Citizenship Paper (Form N-565). 

9. Any other documents which establish a U.S. place of birth or indicate U.S. citizenship. 

LIST B 

ACCEPTABLE DOCUMENTS TO ESTABLISH ALIEN STATUS 

An alien lawfully admitted for permanent residence under the Immigration and Naturalization Act (INA) must submit supporting documentation 

to establish legal presence under one of the following categories: 

1. An alien lawfully admitted for permanent residence under the Immigration and Naturalization Act (INA). Evidence includes: 

Χ INS Form I-551 (Alien Registration Receipt Card commonly known as a “green card”); or 

Χ Unexpired Temporary I-551 stamp in foreign passport or on INS Form I-94. 

2. An alien who is granted asylum under Section 208 of the INA. Evidence includes: 

Χ INS Form I-94 annotated with stamp showing grant of asylum under Section 208 of the INA; 

Χ INS Form I-688B (Employment Authorization Card) annotated “274a.12(a)(5)”; 

Χ INS Form I-766 (Employment Authorization Document) annotated “A5"; 

Χ Grant Letter from the Asylum Office of INS; or 

Χ Order of an immigration judge granting asylum. 

3. A refugee admitted to the United States under Section 207 of the INA. Evidence includes: 

Χ INS Form I-94 annotated with stamp showing admission under Section 207 of the INA; 


Χ INS Form I-766 (Employment Authorization Document) annotated “A3"; or 

Χ INS Form I-571 (Refugee Travel Document). 

4. An alien paroled into the United States for at least one year under Section 212(d)(5) of the INA. Evidence includes: 

Χ INS Form I-94 with stamp showing admission for at least one year under Section 212(d)(5) of the INA. 

5. An alien whose deportation is being withheld under Section 243(h) of the INA (as in effect immediately prior to September 30, 1996) 

or Section 241(b)(3) of such Act (as amended by Section 305(a) of Division C of Public Law 104-208). Evidence includes: 


Χ INS Form I-766 (Employment Authorization Document) annotated “A10"; or 

Χ Order from an immigration judge showing deportation withheld under Section 243(h) of the INA as in effect prior to April 1, 

1997, or removal withheld under Section 241(b)(3) of the INA. 

6. An alien who is granted conditional entry under Section 203(a)(7) of the INA as in effect prior to April 1, 1980. Evidence includes: 

Χ INS Form I-94 with stamp showing admission under Section 203(a)(7) of the INA; 

Χ INS Form I-688B (Employment Authorization Card) annotated “274a.12(a)(3)”; or 

Χ INS Form I-766 (Employment Authorization Document) annotated “A3". 

7. An alien who is a Cuban or Haitian entrant (as defined in Section 501(e) of the Refugee Education Assistance Act of 1980). Evidence 

includes: 

Χ INS Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”) with the code CU6, CU7, or CH6; 

Χ Unexpired temporary I-551 stamp in foreign passport or on INS Form I-94 with code CU6 or CU7; or 

Χ INS Form I-94 with stamp showing parole as “Cuban/Haitian Entrant” under Section 212(d)(5) of the INA. 

8. An alien paroled into the United States for less than one year under Section 212(d)(5) of the INA. Evidence includes: 

Χ INS Form I-94 showing this status. 

9. An alien who has been declared a battered alien. Evidence includes: 

Χ INS petition and supporting documentation. 

status. 

The preceding lists (A and B) contain the most common documents, which can be used to establish U.S. Citizenship or legal alien

MENTAL HEALTH PROFESSIONS LICENSING BOARD 


Cheyenne WY 82002 

http://plboards.state.wy.us/mentalhealth 

WyoMHPLB@wyo.gov 

APPLICATION 

Specific requirements are detailed in the Rules and Regulations which are available on our web page. Review the requirements prior to submitting your application. 

Please type or print legibly, preferably in blue ink. The Board will only accept originally signed applications. Before mailing be sure to include: 

Proof of legal presence as required by item #3 of the application. Applicants generally find it easiest to provide a copy of their social security card, or a copy of 

their passport, or a copy of their government issued birth certificate. Originals will not be returned. If you are unable to provide a copy of any of these documents 

please refer to the enclosed list A and B. A copy of your driver’s license IS NOT an acceptable form of identification for proof of legal presence. 

Payment of the application fee. Make checks payable to the “State of Wyoming”. Do not send cash. All fees are non-refundable regardless of the outcome. 

Incomplete applications WILL NOT be reviewed. 

Select from these check boxes if you are applying for certification at the bachelor’s degree level or equivalent, or with specialty training for the CAPA. 

ADDICTIONS PRACTITIONER 

ADDICTIONS PRACTITIONER ASSISTANT 

DISCIPLINE: 

(One only) 

SOCIAL WORKER 

METHOD: 

(One only) 

EXAMINATION 

RECIPROCAL 

Select from these check boxes if you are applying for licensure at the master’s degree level. 

ADDICTIONS THERAPIST 

PROVISIONAL 

DISCIPLINE: CLINICAL SOCIAL WORKER 

METHOD: COMPLETING PROVISIONAL 

(One only) MARRIAGE AND FAMILY THERAPIST (One only) EXAMINATION 

PROFESSIONAL COUNSELOR 

RECIPROCAL 

$300.00 fee 

$300.00 fee 

$150.00 fee 

$200.00 fee 

$350.00 fee 

$350.00 fee 

1. NAME: 

2. 

3. 

SOCIAL 

SECURITY: 

LEGAL 

PRESENCE: U.S. OTHER 

Last First Middle Initial Previous Names Used 

DATE OF 

BIRTH: 

(U.S. Code Title 8, Chapter 14, Section 1621 requires proof of legal presence in the United States. Attach 

acceptable documentation from enclosed List A and B.) 

TELEPHONE NUMBER(S): 

4. 

HOME 

ADDRESS: 

Street Address 

( ) 

Home 

5. 

CURRENT 

EMPLOYER: 

( ) 

City State Zip Cell 

Business Name 


6. 

BUSINESS 

ADDRESS: 


( ) 

Phone 

( ) 

City State Zip Fax 

7. PREFERRED MAILING ADDRESS: HOME BUSINESS 

8. 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. 

Revised 8/2013

9. REGISTRATION: Indicate registration(s), license(s), or certification(s) in all states, including Wyoming, where you are currently or 

have been previously registered, licensed or certified in any profession. Begin with your original registration, license or certification. Note 

carefully any registrations, licenses or certifications not currently in good standing. Refer to the application instructions for additional 

direction. 

Addictions Therapy 

Clinical Social Work 

Marriage and Family Therapy 

Professional Counseling 

*Any Other Discipline 

STATE(S) 

CERTIFIED 

*Specify certification title and level if applicable: 

CERTIFICATE 

NUMBER 

ISSUE 

DATE 

EXPIRE 

DATE 

CURRENT 

STATUS 

10. EDUCATION: List any universities or colleges attended that satisfy the educational requirement in the discipline for which 

licensure or certification is sought. Refer to the application instructions for additional direction. 

UNIVERSITY/COLLEGE CITY/STATE DEGREE(S) DATE(S) MAJOR(S) 

11. PROFESSIONAL REFERENCE: Name three (3) persons who will be submitting professional reference forms to the Board. Refer 

to the application instructions for additional direction. 

NAME ADDRESS TELEPHONE 

( ) 

( ) 

( ) 

12. CERTIFICATION: Indicate professional certifications/credentials which you currently or have previously held in any mental health 

discipline, from organizations such as NBCC, NASW, NAADAC, AAMFT, etc. Refer to the application instructions for additional direction. 

PROFESSIONAL 

ORGANIZATION 

CERTIFICATION 

TYPE AND NUMBER 

ISSUE 

DATE 

EXPIRE 

DATE 

CURRENT 

STATUS 

Revised 8/2013

13. EXPERIENCE: List below your training/work experience. Begin with today and work back in time. Note any interruptions in time, 

such as periods of unemployment and/or education. Refer to the application instructions for additional direction. 

From: To: Supervisor: 

Month/Year 

Month/Year 

Organization: 

Address: 

Brief Description of Work: 


Month/Year 

Month/Year 

Organization: 

Address: 



Month/Year 

Month/Year 

Organization: 

Address: 



Month/Year 

Month/Year 

Organization: 

Address: 


Revised 8/2013

HISTORY 

14. Have you ever, or are you now, providing any of the services regulated by W.S. 33-38-101 et seq. in the 

State of Wyoming, without meeting the requirement for licensure or certification, or without meeting an 

exemption provided in W.S. 33-38-103 

Yes No 

15. Has any state rejected or denied your application for certification or licensure in any profession Yes No 

16. Has any state revoked, suspended, refused to renew, or otherwise restricted your certificate or license in 

any profession 

17. Have you ever voluntarily surrendered your certificate or license in any profession in order to avoid 

disciplinary action by a regulatory agency in any state 

Yes No 

Yes No 

18. Have you ever been sanctioned by a professional association Yes No 

19. Have you been convicted of a misdemeanor involving moral turpitude, including pleas of nolo contendere 

or no contest 

Yes No 

20. Have you been convicted of a felony in any profession, including pleas of nolo contendere or no contest Yes No 

21. Are you addicted to, or do you habitually use alcohol, any controlled substance, or other drugs having 

similar effects 

Yes No 

22. Have you ever been judged incompetent by a court of law Yes No 

23. Have you ever violated and been convicted of a charge under the Wyoming Controlled Substances Act Yes No 

Attach a written explanation if you answered "YES" to any of questions 14 through 23 above. Include documentation related to your 

“YES” answer(s), including, but not limited to, certified copies of court records, letters of sanction, state board disciplinary action 

documents, etc. 

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.) 

AGREEMENT 

In signing this application, I do hereby state that 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 also agree to adhere to the codes of ethics 

applicable to my profession and this application. 

AFFIDAVIT 

The undersigned, being duly sworn, deposes and says that he or she is the person making the foregoing statements and that they are 

made in good faith and are true in every respect. 

SIGNATURE OF APPLICANT 

DATE 

Revised 8/2013





PROFESSIONAL REFERENCE 

Please type or print legibly, preferably in blue ink. The Board will only accept originally signed references. 

To: 

Mental Health Professions Licensing Board 

From: 

Date: 

Applicant: 

The person named above has made an application to become licensed or certified as a mental health professional in the state of Wyoming. Applicants 

are required to demonstrate their integrity, professionalism and character in the field through professional recommendations which attest to applicants’ 

abilities and professional performance. Board Rules and Regulations require individuals providing professional references to have at least six (6) 

months of direct knowledge of such experience by the applicant. Please respond to the following questions: 

1. How long have you known the applicant 

2. What is your relationship to the applicant 

3. Please describe the situations in which you have observed the applicant engaged in clinical practice. 

4. Is the applicant currently engaged in clinical practice Yes No (Comments) 

5. In your opinion, does the applicant possess the personal and professional integrity to practice clinically in the 

mental health field Yes No (Comments) 

6. How does the applicant demonstrate respect for the client-therapist relationship 

Revised 8/2013

7. How does the applicant demonstrate knowledge regarding current ethical issues in clinical mental health practice 

8. To your knowledge, has there ever been any concern regarding this applicant’s ethical conduct Yes No (Comments) 

9. Do you have any reason to believe that this applicant should not be granted licensure or certification in a 

mental health profession Yes No (Comments) 

10. Do you believe that on an overall basis, including ethics, conduct, character, and competence, this applicant 

is or would be a credit to the mental health profession Yes No (Comments) 

SIGNATURE 

DATE 


Address: 


( ) 

Business 

E-mail 

Address: 

( ) 

City State Zip Cell 

Please provide an e-mail address that you check regularly. If there are any questions or issues regarding your reference, the Board 

staff will communicate with you at this address. 

Per Wyoming Statute § 16-4-203(d)(iv) letters of reference are not subject to the public right of inspection. Therefore, any 

comments that you provide will remain confidential between yourself and the Board. 

The signed reference may be e-mailed to WyoMHPLB@wyo.gov, or faxed to (307) 777-3508, or mailed to the address provided on this form. 

Revised 8/2013





WyoMHPLB@wyo.gov 

STATE LICENSE/CERTIFICATION VERIFICATION 

APPLICANT COMPLETE THIS SECTION 

Complete ONLY this portion of the form, sign, and forward to a state regulatory agency where you are currently or have 

been previously licensed or certified as referenced on your application. 

1. NAME: 

Last First Middle Initial Previous Names Used 

2. 

SOCIAL 

SECURITY: 

DATE OF 

BIRTH: 

3. ADDRESS: 

TELEPHONE NUMBER: 

( ) 

Please read and sign below: 

I am applying for a licensure or certification in the State of Wyoming. I acknowledge and agree that the Mental 

Health Professions Licensing Board has a valid interest in obtaining and verifying information concerning my 

professional competence. Accordingly, I consent to the release by any person to the Mental Health Professions 

Licensing Board all information that may reasonably be relevant to an evaluation of my professional 

competency, character and moral and ethical qualifications, including any information relating to any disciplinary 

action, suspension or curtailment of privileges, and hereby release any such person providing such information 

from any and all liability for doing so. 

SIGNATURE OF APPLICANT 

DATE 

STATE REGULATORY AGENCY COMPLETE THE REMAINDER OF THIS FORM 

The Board has received an application for licensure from the person named above. The Board, as well as the applicant, 

would appreciate your providing the information required and returning this form directly to the Board at the above address. 

This information will be kept confidential by the Board, although the applicant may be informed by the Board as to whether 

the information is generally favorable or unfavorable. The information provided will not be reviewed unless all areas of this 

form are completed. Incomplete forms will not be accepted and will be returned to the regulatory agency. 

4. AGENCY: 


5. ADDRESS: 

( ) 

6. 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. 

Revised 8/2013

7. LICENSED OR CERTIFIED AS: NUMBER 

ISSUE 

DATE 

EXPIRATION 

DATE 

GOOD 

STANDING 

Licensed Addictions Therapist 

Yes No 

Licensed Clinical Social Worker 

Yes No 

Licensed Marriage and Family Therapist 

Yes No 

Licensed Professional Counselor 

Yes No 

Certified Addictions Practitioner 

Yes No 

Certified Social Worker 

Yes No 

Other: 

Yes No 

8. LICENSURE OR CERTIFICATION WAS GRANTED BY: 

Examination Reciprocity Grandfather Other 

State 

9. MINIMUM EDUCATIONAL REQUIREMENT: 

10. MINIMUM HOURS OF CLINICAL SUPERVISED EXPERIENCE REQUIRED: 

11. MINIMUM HOURS OF CLIENT CONTACT HOURS REQUIRED: 

12. MINIMUM HOURS OF INDIVIDUAL FACE-TO-FACE SUPERVISION REQUIRED: 

13. QUALIFICATIONS OF SUPERVISOR: 

14. EXAMINATION REQUIRED: 

EXAM 

LEVEL 

If applicable 

DATE 

OF 

EXAM 

CANDIDATE 

RAW 

SCORE 

NATIONAL 

MEAN 

Pass score 

ASWB 

AMFTRB 

NBCC 

NAADAC 

Other: 

15. HAS THIS APPLICANT EVER BEEN DENIED LICENSURE OR CERTIFICATION BY YOUR AGENCY Yes No 

(If " YES" please provide an explanation.) 

16 HAS THIS APPLICANT’ S LICENSE OR CERTIFICATION EVER BEEN IN A PROBATIONARY 

STATUS, VOLUNTARILY SURRENDERED, REVOKED, SUSPENDED OR LIMITED IN ANY WAY Yes No 

(If " YES" please attach a copy of the Consent Agreement or the Findings of Facts, Conclusions of Law and Order.) 

Signature 

Date 

Title 

Revised 8/2013

LICENSURE REQUIREMENTS FOR PROFESSIONAL COUNSELOR

Create successful ePaper yourself

Delete template?

Save as template?