Approved ____________________________

STATE OF LOUISIANA 

LICENSED PROFESSIONAL COUNSELORS BOARD OF EXAMINERS

REGISTRATION OF SUPERVISION:  PART I

APPLICANT DATA AND EDUCATIONAL REQUIREMENTS                      

INSTRUCTIONS:

You may register as a counselor intern using Part I of this form as soon as you have completed the educational requirements specified by the board. However, when you secure a board approved LPC supervisor, you must complete Part II, the SUPERVISOR DATA form, and send it to the board office. When you secure an employment or volunteer setting to practice counseling, you must complete Part III, the PRACTICE SETTING form, and send it to the board office. You may not practice counseling until all three parts of this form have been submitted. In the future, each time your supervisor or practice setting changes, you must complete and submit Part II or Part III of this form to update your file.

Send the following to the board office to register as a counselor intern:

·    A completed Transcript Form indicating the areas you believe your coursework covers.

·    Official graduate transcript(s) must be forwarded directly from each college or university to the Board office.

·    FEE: Please include appropriate fee of $100 in the form of a Money Order, Cashier's Check or Certified Check.   (PERSONAL CHECKS WILL BE SENT BACK)

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

APPLICANT DATA

Applicant  ____________________________________________________________________________

                                                          (First)                               (Middle/Maiden)                                                (Last) 

Current Address ________________________________________________________________________

                                                (Street)                                                      (City/State)                                                (Zip) 

Telephone  (H) ______________________    (W) _____________________ (Cell) ___________________ 

E-mail ____________________________________________________

Mailing Address to use on LPC Website _____________________________________________________

City/State/Zip __________________________________________________________________________

SSN ______________________________________   Date of Birth ________________________________

Have you ever been convicted of a felony? ____Yes, ____ No. If yes, state the felony, date of conviction, name, location of court (City, Parish, State) on a separate attached sheet. Also, if conviction was set aside, give date and explain using a separate attached sheet.

 

                                                                                                                                                                     REGISTRATION OF SUPERVISION:  PART I

EDUCATIONAL REQUIREMENTS

Name on transcript if different from now_____________________________________________________

University/College ______________________________________________________________________

Location ______________________________________________________________________________

Dates Attended ________________________     Date of Graduation _______________________________

Degree _______________Major _________________________________________ Hours in Degree ____

Is your program CACREP accredited?  ____ Yes   ____ No

Is your university regionally accredited (e.g., SACS) ?  ____ Yes  ____ No

Have you taken the National Counselor Examination (NCE)?  _____Yes _____ No

Exam Score __________________           Date Exam was taken ______________________________

(Please note: The NCE does not need to be passed prior to registration as a Counselor Intern; however, it must be passed prior to approval of licensure.)

Part I of this form must be submitted as your application to register with the board. As soon as you have secured a supervisor and practice setting, submit Part II and Part III. You may not practice counseling until all three parts of this form have been submitted and you have received notification that you may begin to practice.