LICENSURE REQUIREMENTS FOR PROFESSIONAL COUNSELOR

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