Oklahoma Administrative Code
Title 86 - State Board of Behavioral Health Licensure
Chapter 20 - Licensed Behavioral Practitioners
Subchapter 3 - Forms
Section 86:20-3-2 - Description of forms

Universal Citation: OK Admin Code 86:20-3-2

Current through Vol. 41, No. 13, March 15, 2024

(a) The Application Form requires the following:

(1) Identifying information of applicant;

(2) Possession of other credentials;

(3) Previous misconduct;

(4) Education;

(5) References; and

(6) Proposed professional Practice.

(b) The Internship/Practicum Documentation Form requires the following:

(1) Identifying information of applicant;

(2) Place, time, duration and nature of supervised experience;

(3) School arranging supervision and name of supervisor; and,

(4) Signature and title of supervisor.

(c) The Supervision Agreement requires identifying information of supervisee and supervisor as follows:

(1) Name of candidate;

(2) Name of candidate's place of employment;

(3) Location supervised experience hours are being accrued;

(4) Candidate's contact information;

(5) Signature of Candidate;

(6) Name of Approved LBP Supervisor;

(7) Name of Approved LBP Supervisor's place of employment;

(8) LBP Approved Supervisor's contact information;

(9) Signature of LBP Approved Supervisor;

(10) Name of On-Site Supervisor;

(11) On-Site Supervisor's licensure information;

(12) Name of On-Site Supervisor's place of employment;

(13) On-Site Supervisor's contact information;

(14) Signature of On-Site Supervisor.

(d) The Evaluation of Supervised Experience Form requires the following:

(1) Names of supervisee and supervisor;

(2) Name and location of supervision site;

(3) Duration of work experience and supervision;

(4) Types of professional activities and clients seen;

(5) Rating of quality of professional activities;

(6) Supervisor and supervisee comments; and

(7) Signatures of supervisee and supervisor.

(e) 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;

(11) Signature and identifying information of person verifying from out-of-state.

(f) The Termination of Supervision Agreement requires the following information:

(1) name of candidate;

(2) current place of employment of candidate;

(3) address of current place of employment of candidate;

(4) phone number of candidate;

(5) email address of candidate;

(6) signature and signature date of candidate, (if available);

(7) name of supervisor;

(8) license number of supervisor;

(9) current place of employment of supervisor;

(10) phone number of supervisor;

(11) email address of supervisor;

(12) signature and signature date of supervisor, (if available); and

(13) effective date of termination of supervision agreement.

Disclaimer: These regulations may not be the most recent version. Oklahoma may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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