LICENSURE REQUIREMENTS FOR PROFESSIONAL COUNSELOR

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