LICENSURE REQUIREMENTS FOR PROFESSIONAL COUNSELOR

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