Current through Vol. 42, No. 1, September 16, 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 Document of Recommendation requires the following:
(1) Identifying information of
applicant;
(2) Scale of performance
rating personal character and professional skills;
(3) Circumstances and time period rater has
known applicant;
(4) Space for
rater's comments;
(5) Identifying
information of rater.
(d) The Statement of Professional Disclosure
is composed of alternative forms depending on the status of the applicant, as
follows.
(1) The LBP Candidate's Statement of
Professional Disclosure requires the following:
(A) Explanation of LBP Candidate's
responsibilities;
(B) Name and
contact information for person who will be responsible for the client's records
in the event of the LBP Candidate's infirmity or death;
(C) Supervisor's identifying
information;
(D) Address and phone
number of the Department; and,
(E)
Signatures of client and LBP Candidate.
(2) The LBP's Statement of Professional
Disclosure requires the following:
(A)
Explanation of the LBP's responsibilities;
(B) Name and contact information for person
who will be responsible for the client's records in the event of the LBP's
infirmity or death;
(C) Address and
phone number of the Department; and,
(D) Signatures of client and LBP.
(e) The Supervision
Agreement requires the following:
(1)
Statement of agreement to fulfill Subchapter 15 and consequences of violation;
and
(2) Identifying information and
signatures of supervisee and supervisor.
(f) The On-Site Supervisor Verification Form
requires the following identifying information:
(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.
(g) 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.
(h) The Continuing Education Roster requires
the following:
(1) LBP's name and license
number;
(2) Total number of hours
accrued and LBP's signature and signature date of licensee;
(3) Listing of workshops, sponsor, content
and date of continuing education experience.
(i) The Licensure Verification Request Form
requires the following information:
(1) Name
of licensee;
(2) Licensee license
number; and
(3) Licensee license
type.
(j) 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.
(k) The Mailing Addresses
Request/Order Form requires the following information:
(1) Type of licensure list
requested;
(2) Format
requested;
(3) Identifying
information of person making request.
(l) 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;
(6) Dates of inactivation
and reactivation of license.
Transferred from
310:403-5-2
by Laws 2013, c. 229, § 3(F), eff 11-1-13 (see Editor's Note at beginning
of this Chapter)
