State of Louisiana
LICENSED PROFESSIONAL COUNSELORS BOARD OF EXAMINERS
8631 Summa Ave, Baton Rouge, LA 70809
www.lpcboard.org e-mail: lpcboard@eatel.net
INSTRUCTIONS
This form is to be used by applicants applying to the Licensed Professional Board of Examiners for approval as a Board Approved (LMFT) Licensed Marriage and Family Therapist Supervisor. Specific approval requirements for Board Approved LMFT Supervisor and LMFT Registered Supervisor Candidate can be reviewed in Section 3315, paragraph D, of Title 46, Part LX, Subpart 2 Professional Standards for Licensed Marriage and Family Therapists. If any information provided in this application changes during the applicant’s tenure as an Approved LMFT Supervisor, the applicant must inform the LPC Board of Examiners within thirty (30) days.
Consult the qualifications for application and fill out the application completely and accurately. An incomplete or inaccurate application is reason for denial. Note that required documentation must be sent directly from the submitting institutions or supervisors to the Board of Examiners. Except when otherwise specified, transcripts or documentation sent directly from the applicant will not be accepted. Note that all applicants must submit documentation of at least 2 years experience as a Licensed Marriage and Family Therapist. Supervision of supervision shall not be done via video-conferencing, online, or any other electronic method.
APPLICATION FOR
LICENSED MARRIAGE & FAMILY THERAPIST (LMFT) BOARD APPROVED SUPERVISOR
I understand that, in addition to submitting all applicable sections of this form, I must submit documentation of 1.) 2 years experience as a Licensed Marriage and Family Therapist, 2.) completion of a Board approved one-semester graduate course of study in marriage and family therapy supervision (or its equivalent, as approved by the Advisory Committee and Board, AND 3.) that my Approved Supervisor will directly submit the Documentation of Supervision-of-Supervision form (Appendix "B" of this application) documenting my successful completion of my Plan of Supervision-of-Supervision. Please note that you may have already completed steps 1 and 2 if you have been approved as a Registered Supervisor Candidate and do not need to submit this information again.
A. GENERAL INFORMATION
Name:
______________________________________________________
First Middle Last
Home Address:
______________________________________________
Street
___________________________________________
City/State/Zip
Social Security Number: __________________________
Date of Birth: ____________________
Home Telephone: _____________________
First Business Phone ____________________
Second Business Phone _____________________
Cell Phone ________________________
Email Address_____________________________________
Applicant’s Title/Position _______________________________________
Employer or Place of Business:_________________________________
Business Address:
________________________________________________________
Street
________________________________________________
City/State/Zip
Second Work Address, if applicable
______________________________________________________________
Street
___________________________________________________________
City/State/Zip
Check preferred mailing address and LPC Board Website Listing: (___) Home Work (___) First Number; (___) Second Number
Have you ever been denied a professional license and/or certificate? Yes ___ No ___ If yes, state reason:
Are you currently under investigation for any unprofessional/illegal activity? Yes ___ No ___ If yes, state reason:
Has any action been taken to suspend/revoke your license/certification? Yes ___ No ___ If yes, please state date, type of action, name and address of entity taking action:
Have you ever been convicted of a felony? Yes ___ No ___ If yes, please state the felony, date of conviction, location of court (City, Parish, County, State) on a separate attached sheet. Also, if conviction was set aside or if a pardon was obtained, give date and explain using a separate sheet.
B. PHOTOGRAPH: Applicants not licensed in Louisiana must provide a recent 2"x 3" photograph. Picture must be a frontal view showing the applicant's head and shoulders. Sign name on back of picture. You do not need to provide a recent photograph if you are licensed in Louisiana.
C. CERTIFICATE LETTERING: All applicants please type or print your name how you would like for it to appear on your certificate should you be approved by the Board. DEGREE TITLES, HONORS OR OTHER INFORMATION WILL NOT BE ADDED.
(NAME) _____________________________________________________
D. AFFIDAVIT: Must be notarized.
I, ______________________, being duly sworn, do hereby affirm that I am the person referred to in this application for approval as a Board Approved Licensed Marriage and Family Therapist Supervisor in the State of Louisiana and that all the foregoing statements and enclosures are true in every respect. I affirm that I will inform the LPC Board of Examiners in writing within thirty (30) days if any information that I have provided changes during my tenure as a Board Approved LMFT Supervisor. Should I furnish any false information in this application, I hereby agree that such act shall constitute cause for the denial, suspension, or revocation of my license as a Licensed Marriage and Family Therapist in the State of Louisiana. I also have read the Documentation of Supervision of Supervision form that my supervisor has filled out and sent directly to the LPC Board and certify that the information therein is complete and accurate.
State of Louisiana
Parish/County of:__________________________________________________
Applicant Signature: _______________________________________________
Subscribed and sworn before me this _______Day of _______________, 20______
Notary Public Signature ________________________________________________________________
Notary Public Name (typed or printed):
__________________________________________________________
Notary Public Seal My Commission Expires:______________________
The LPC Board reserves the right to secure further information or evidence that it deems reasonable and proper.
E. LICENSURE AND CERTIFICATION
Please list below your licensure in Louisiana or another state: as a Licensed Marriage and Family Therapist and/or all other professional license(s) to practice counseling, social work, or any other related profession.
____________________________________________________________
Type of License No. Issuing State Expiration Date
____________________________________________________________
Type of License No. Issuing State Expiration Date
In addition to licenses, list any professional certifications:
___________________________________________________________
Type No. Issuing State Expiration Date
APPENDIX
DOCUMENTATION OF SUPERVISION-OF-SUPERVISION
Please have your Board Approved LMFT Supervisor fill out this form is to be filled out and send it directly to the LPC Board.
I, __________________________ (Please print or type your name)
certify that _____________________________(Please print or type name), has successfully completed his/her plan of supervision-of-supervision filed with the LPC Board of Examiners. I therefore recommend him/her for approval as a Licensed Marriage and Therapist Supervisor.
I further certify that the supervision hours documented below reflect a minimum of 36 clock hours spent in face-to-face in person consultation with the applicant in his/her supervision of MFT interns or LMFTs therapists practicing marriage and family therapy. This supervision of supervision was not be done via video-conferencing, online, or any other electronic method.
.
Date supervision began _______________________
Date supervision plan was complete ______________
Hours of supervision-of-supervision ____________
Supervisor’s/Candidate’s comments:
Signature of Approved Supervisor __________________________________
Date _______________
Updated February 2007