Current through Vol. 42, No. 1, September 16, 2024
(a) Each
application shall include the following documents:
(1) Application form,
(2) Official transcript, mailed from the
university or college,
(3) Three
(3) Document of recommendation forms,
(4) Practicum documentation form,
(5) Two (2) classifiable sets of
fingerprints, and
(6)
Fees.
(b) The
Application Form requires the following:
(1)
Identifying information;
(2)
Possession of other credentials;
(3) Previous misconduct;
(4) Education;
(5) References; and
(6) Proposed professional practice.
(c) The Internship/Practicum
Documentation form requires the following:
(1) Identifying information; and
(2) Time, place, location of
practicum.
(d) The
Document of Recommendation requires the following:
(1) Identifying information;
(2) Ratings of ethical and professional
characteristics; and
(3)
Circumstances and time period submitter has known applicant.
(e) The Statement of Professional
Disclosure requires the following:
(1)
Statement providing for the applicant's disclosure of professional standing;
and
(2) Statement providing for
making contact with OSDH for further information.
(f) The Supervision Agreement requires
identifying information of supervisee and supervisor.
(g) The On-Site Supervisor Verification Form
requires identifying information as follows:
(1) Name of applicant;
(2) Place of employment;
(3) On-Site Supervisor information;
(4) A reproduction of the regulation
regarding supervision accrued in a private setting.
(h) The Licensure Verification Request Form
requires the following information:
(1) Name
of licensee;
(2) Licensee license
number; and
(3) Licensee license
type.
(i) The
Out-of-State Licensure Verification Form requires the following information:
(1) Identifying information;
(2) Type of credential held in other
state;
(3) License
number;
(4) Issue and expiration
date of license;
(5) Current
standing of license;
(6) Past
complaints or sanctions;
(7) Exam
information;
(8) Supervision
information;
(9) Graduate
education;
(10) Internship
documentation; and
(11) Signature
and identifying information of person verifying from out-of-state.
(j) The Mailing Addresses
Request/Order Form requires the following information:
(1) Type of licensure list
requested;
(2) Format requested;
and
(3) Identifying information of
person making request.
(k) The Licensure Reactivation Request Form
requires the following information:
(1)
Licensure type;
(2) Identifying
information;
(3) Employment
information;
(4) Graduate
education;
(5) License type and
number; and
(6) Dates of
inactivation and reactivation of license.
(l) The LPC Continuing Education Approval
Application Form requires the following information:
(1) name of workshop;
(2) program context;
(3) program knowledge area;
(4) name of presenter;
(5) presenter qualifications;
(6) number of hours requested;
(8) sponsoring agency;
(9) name of contact;
(10) phone number of contact;
(11) signature and signature date of
contact;
(12) program content in
relation to counseling ethics;
(13)
program content in relation to counseling supervision;
(14) number of hours requested for counseling
ethics; and
(15) number of hour
requested for counseling supervision.
(m) The Continuing Education Rosters for LPC
Approved Supervisors require the following information:
(1) name of licensee;
(2) signature and signature date of
licensee;
(3) total clock hours of
workshop(s);
(4) name of counseling
supervision workshop;
(5)
sponsoring agency of workshop(s); and
(6) date of workshop(s), and number of hours
of each workshop.
Transferred from
310:405-7-2
by Laws 2013, c. 229, § 3(F), eff 11-1-13 (see Editor's Note at beginning
of this Chapter)
