BOARD OF EXAMINERS

MFT INTERN REGISTRATION OF SUPERVISION SECTION 2:

PRACTICE SETTING

INSTRUCTIONS:

This form is to register your practice setting/volunteer position. You must also have submitted SECTION 1 and paid the fee of $100.00 before you can register your practice setting. Both forms may be submitted at the same time. You may not practice marriage and family therapy or begin to count supervision hours until all three sections of this form have been submitted and approved. In the future, each time your supervisor or practice setting changes you must complete and submit SECTION 2 and SECTION 3 to update your file.

Mail to: LPC Board of Examiners, 8631 Summa Avenue, Baton Rouge, LA 70809

Phone 225/765-2515 C FAX 225/765-2514

Email lpcboard@eatel.net C Website www.lpcboard.org

Applicant Name_____________________________________________________________

Current Address _____________________________________________________________

City/State/Zip _______________________________________________________________

Home Telephone __________________ Business Telephone __________________________

Email ____________________

COMPLETE ONE OR BOTH SECTIONS BELOW AS NEEDED

Note that you cannot practice independently as an MFT Intern unless you are licensed in another mental health profession.

PRIVATE PRACTICE SETTING

Name of Private Practice Where You Will Be Working ______________________________________________________________________________

Address of Private Practice________________________________________________________

______________________________________________________________________________

Describe briefly the nature of the private practice setting where your supervision will take place including a brochure, pamphlet, or other written information, if available.

______________________________________________________________________________

Identify the individual(s) who have an ownership interest in the practice (Include their degree and licensure information.).

______________________________________________________________________________

Applicant 's proposed position and title ______________________________________________

Date of applicant's initial employment ______________________________________________

Total hours per week applicant will be working________________________________________

Anticipated completion date for supervision __________________________________________

Describe the nature of the duties to be performed by applicant. Include specifics of the types of cases, ages of clients, etc. (Attach additional sheet if necessary.)

______________________________________________________________________________

Describe the type of clientele to be seen by applicant including range of clients, nature of presenting problems, demographic data, etc.

______________________________________________________________________________

Describe types of assessment procedures, intervention activities and therapeutic approaches to be used by applicant.

______________________________________________________________________________

NON PRIVATE PRACTICE SETTING (employment or volunteer)

(If more than one setting will be used, provide information for all settings).

Institution Name ________________________________________________________________

Institution Address ______________________________________________________________

______________________________________________________________________________

Describe briefly the nature of the training setting where supervision will take place including a brochure, pamphlet, or other written information, if available.

______________________________________________________________________________

Applicant's proposed position and title ______________________________________________

Date of applicant's initial employment ______________________________________________

Total hours per week applicant will be working _______________________________________

Anticipated completion date for supervision __________________________________________

Describe the nature of the duties to be performed by applicant. Include specifics of the types of cases, ages of clients, etc. (Attach additional sheet if necessary.)

______________________________________________________________________________

Describe the type of clientele to be seen by applicant including range of clients, nature of presenting problems, demographic data, etc.

______________________________________________________________________________

Signature of Applicant

_________________________________________________ Date _______________________

STATEMENT OF SUPERVISOR

I have reviewed this proposal for the practice setting for this applicant's MFT Intern supervision and accept this intern.

Signature of Supervisor

_________________________________________________ Date _______________________

THE BOARD MEETS THE THIRD FRIDAY OF MOST MONTHS BE SURE TO CHECK THE WEBSITE FOR EXACT DATE.

COMPLETE APPLICATIONS MUST BE IN THE BOARD OFFICE BY THE SECOND FRIDAY OF THE MONTH OR THE FRIDAY BEFORE THE MEETING DATE.