Approved ______________________________

LICENSED PROFESSIONAL COUNSELORS BOARD OF EXAMINERS

REGISTRATION OF SUPERVISION PART II

SUPERVISOR DATA

Applicant Name ______________________________________________________________

Current Address ______________________________________________________________

City, State, Zip ________________________________________________________________

Home Telephone ___________________________ Business Telephone ___________________

E-mail _________________________________________

INSTRUCTIONS:

This form is to register your board approved LPC supervisor  with the LPC Board. You must also have submitted Part I of this form and paid the fee of $100.00 before you can register your supervisor. (Or you may submit Part II and III at the same time as Part I.)

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

SUPERVISOR DATA

Supervisor_____________________________________________________________________________                                                                                                                                                                                                        (First)                        (Middle/Maiden)                                        (Last)

Address______________________________________________________________________________                                                                                                                                                                                                       (Street or P O Box)            (City/State)                                            (Zip)    

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

E-mail ______________________________

Is supervisor a relative of the applicant? _____ Yes _____ No

If yes, state relationship____________________________________________________________

_______________________________________________________________________________