1. The licensing Requirements are posted at www.lpcboard.org under FORMS.

2. Complete sections as directed in General Instructions. Type or print clearly. If additional information is needed for

any sections, please attach 8 1/2 X 11 sheets continuing in the same format as that used in the application.

3. Guidelines and rules for writing a Statement of Practice and a sample are posted at www.lpcboard.org under FORMS.

4. Documentation of Experience.

5. FEE: Please include appropriate fee in the form of a Money Order, Cashier's Check, or Certified Check. (FEES ARE NONREFUNDABLE)

6. Mail the completed application to the following address:

Dr.

Name: Mr.___________________________________________________________________________________

                   Ms.             (First)                                          (Middle)                                                 (Last)

Home Address:

(Street) _____________________________________________________________________________________

(City)________________________________ (State) _____________(Zip)__________________

Employer or Place of Business: ____________________________________________________________________

Work Address:

(Street) _____________________________________________________________________________________

(City)______________________________________(State)__________________________(Zip)_______________

Check preferred mailing address and LPC Board Website Listing: (____)Home (____)Work

Home Telephone: ( ) Business Telephone: ( ) ___________________________

Cell Phone: ( ) E-mail Address:___________________________

Social Security Number: _________________________________Date of Birth: ____________________________

Place of Birth: (City) ______________________________ (State) ____________ (Zip)_____________________

Have you ever been denied a professional license and/or certificate: Yes ___ No ___ If yes, state reason:

 ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you presently possess a professional license(s) or certificate(s) to practice counseling or related profession issued in Louisiana or another State?

Yes _____ No _____ If yes, please give:

Title License Number(s)__________Issuing State __________ Expiration Date: __________

Title License Number(s)__________Issuing State __________Expiration Date: ___________

Title License Number(s)__________Issuing State __________Expiration Date: ___________

Are you currently certified by a national agency or organization? Yes _____ No _____ If yes, please give:

Title Certificate Number(s)__________Issuing Organization__________Expiration Date: __________

Title Certificate Number(s)__________ Issuing Organization_________ Expiration Date: __________

Title Certificate Number(s)__________ Issuing Organization _________Expiration Date: __________

Has any action been taken to suspend/revoke your license/certification? Yes _____ No _____ If yes, please state date

and type of action: name and address of entity taking such action: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever been convicted of a felony? Yes _____ No _____ If yes, please state the felony, date of conviction, name, 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.

Name on Transcript if different from that used to apply:

University/College:

Dates Attended:__________________________________

Regionally Accredited By:_____________________________________

Date of Graduation: ___________________Degree: _____________________ Major:

Name on Transcript if different from that used to apply:

University/College:

Dates Attended:_________________________________

Regionally Accredited By:_____________________________________

Date of Graduation: ___________________Degree: _____________________ Major:

Name on Transcript if different from that used to apply:

University/College:

Dates Attended:________________________________

Regionally Accredited By:_____________________________________

Date of Graduation: ___________________Degree: _____________________ Major:

C. SUPVERISED CLINICAL EXPERIENCE after the receipt of the qualifying degree: Please list supervised clinical

experience after the receipt of your qualifying degree in the practice of mental health discipline.

A minimum of two years is required for licensure. (Use additional sheets if needed.)

D. PHOTOGRAPH: All applicants 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.

E. LICENSE LETTERING: Please type or print your name how you would like for it to appear on your license should you be approved by the Board. DEGREE TITLES, HONORS OR OTHER INFORMATION WILL NOT BE ADDED.

F. AFFIDAVIT: Must be signed in presence of a notary.

I, the below named applicant, being duly sworn, do hereby affirm that I am the person referred to in this application for licensure as a Licensed Marriage and Family Therapist in the State of Louisiana, and that all foregoing statements and enclosures are true in every respect. 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.

The LPC Board reserves the right to secure further evidence that it deems reasonable and proper from the sources above.

Enclosed in the application is $200.00 made payable to the Licensed Professional Counselors Board of Examiners, WHICH IS NON REFUNDABLE in the form of money order, cashier's check, or bank draft.

PERSONAL CHECKS NOT ACCEPTED.

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:______________________

NOTE: Be sure to check our website for meeting dates. All materials for review must be in the board office the Friday before the meeting.