STATE OF LOUISIANA
LICENSED PROFESSIONAL COUNSELORS BOARD OF EXAMINERS
REGISTRATION OF SUPERVISION: PART III
PRACTICE SETTING
(Note: You must submit separate forms for each practice setting.)
INSTRUCTIONS:
This form is to register your practice setting/volunteer position. You must also have submitted Parts I and II and paid the fee of $100.00 before you can register your practice setting.
Mail this completed form to: LPC Board of Examiners, 8631 Summa Avenue, Baton Rouge, LA 70809.
A copy of your declaration of practices and procedures statement must be included with this application. A sample declaration statement may be found on the LPC Board website (www.lpcboard.org).
Applicant _____________________________________________________________________________
(First) (Middle/Maiden) (Last)
Current Address ________________________________________________________________________
(Street) (City/State) (Zip)
Telephone (H) ________________ (W)__________________ (Cell)_________________
E-mail ____________________________________________________
PRACTICE SETTING INFORMATION
(Reminder: Counselor Interns may not be paid directly for services rendered and may not own a private practice.)
Nature of Practice Setting: ___ Private Practice ___ Agency (paid or volunteer)
Name of Agency/Private Practice __________________________________________________________________
If private practice, identify individual(s) who have an ownership interest in the practice: _____________________
____________________________________________________________________________________________
Address of Agency/Private Practice_______________________________________________________________
Briefly describe the nature of the setting where your internship will take place. You may include a brochure, pamphlet, or other written information, if available.
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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 ____________________
How often will face-to-face supervision generally take place? ______________________________
REGISTRATION OF SUPERVISION: PART III
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Describe the nature of the counseling duties to be performed by applicant. Include specifics of the types of cases (e.g., type of clientele served, typical presenting problems, general demographic data, etc.).
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Briefly describe your therapeutic approach and typical techniques/interventions that you may use in counseling.
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Describe the nature of the supervision (e.g., review tapes, applicant’s case notes, group sessions, etc.). Please note: The use of electronic communication, such as telephones, videos, computers or otherwise, is inappropriate for face-to-face supervision.
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STATEMENT OF APPLICANT
I understand the requirements regarding supervised counseling experience as stated in Chapter 7 §705 of the Board rules. I further understand that I must practice professional mental health counseling only under the supervision of a Board Approved Supervisor until I have successfully completed all of the training requirements and have been licensed. I understand that the minimum acceptable supervised experience shall be 3,000 hours obtained in no less than 24 months, 1,900 of which must be direct service to clients and 100 of which must be supervision hours. If, for any reason, my supervisor or my practice setting should change, I will notify the Licensed Professional Counselors Board of Examiners immediately by submitting a new Part II or Part III of this application. I understand that any supervision obtained without such notification and without the required evaluation form being submitted by my previous supervisor will not be applicable toward the required number of hours for supervision.
Signature of Applicant _______________________________ Date __________________
STATEMENT OF SUPERVISOR
I have reviewed this proposal for supervised professional mental health counseling experience and accept this intern. If I discontinue supervision with this intern, I will advise the Licensed Professional Counselors Board of Examiners and submit the required evaluation form.
Name of supervisor (Please print) ____________________________________________________
Signature of Supervisor ______________________________________ Date _________________
THE BOARD MEETS THE THIRD FRIDAY OF MOST MONTHS. BE SURE TO CHECK THE WEBSITE FOR THE DATE OF THE MEETING. COMPLETE APPLICATIONS MUST BE IN TO THE BOARD OFFICE BY THE SECOND FRIDAY OF THE MONTH.