State of Louisiana
LICENSED PROFESSIONAL COUNSELORS BOARD OF EXAMINERS
8631 Summa Ave, Baton Rouge, LA 70809
www.lpcboard.org e-mail: lpcboard@eatel.net
INSTRUCTIONS FOR REGISTERED SUPERVISOR CANDIDATES
This form is to be used by applicants applying to the Licensed Professional Board of Examiners for registration as a Board Registered Licensed Marriage and Family Therapist (LMFT) Supervisor Candidate. Specific approval requirements for Board Approved LMFT Supervisor and LMFT Registered Supervisor Candidate can be reviewed in Section 3315, paragraph D, of Title 46, Part LX, Subpart 2 Professional Standards for Licensed Marriage and Family Therapists. If any information provided in this application changes during the applicant’s tenure as a Board Registered LMFT Supervisor Candidate, the applicant must inform the LPC Board of Examiners within thirty (30) days and before approval as an LMFT Board Approved Supervisor.
Consult the qualifications for application and fill out the application completely and accurately. An incomplete or inaccurate application is reason for denial. Note that required documentation must be sent directly from the submitting institutions or supervisors to the Board of Examiners. Except when otherwise specified, transcripts or documentation sent directly from the applicant will not be accepted. Note that all applicants must submit documentation of at least 2 years experience as a Licensed Marriage and Family Therapist. Supervision of supervision shall not be done via video-conferencing, online, or any other electronic method.
IMPORTANT NOTE: The required one-semester graduate course in marriage and family therapy supervision must be a graduate level class from a regionally accredited institution (or its equivalent as approved by the Advisory Committee and Board) including a 15-hour didactic component and a 15-hour interactive component. Transcripts submitted as documentation of this class must display these components. Applicants for Registered Supervisor Candidate who have not yet completed this coursework must include a plan for its completion as part of their Plan of Supervision-of-Supervision.
All required transcripts and documentation, including verification of AAMFT Approved Supervisor Candidate status, must be sent directly from the granting institution(s) or supervisor(s) to the LPC Board of Examiners office. Unofficial transcripts or documentation originating with the applicant will not be accepted except where otherwise noted. LMFT Board Approved Supervisors providing documentation of supervision-of-supervision must use the official form designated Documentation of Supervision-of-Supervision (Appendix B of this application).
APPLICATION FOR
BOARD APPROVED LICENSED MARRIAGE & FAMILY THERAPIST (LMFT)
SUPERVISOR CANDIDATE
I understand that I must submit documentation of 1) 2 years experience as a Licensed Marriage and Family Therapist, 2) completion of a Board approved one-semester graduate course of study in marriage and family therapy supervision (or its equivalent, as approved by the Advisory Committee and Board) AND 3) a plan of supervision-of-supervision with a Board Approved LMFT Supervisor using the Plan of Supervision-of-Supervision form (Appendix A of this application).
I further understand that my Approved Supervisor’s submission of the Documentation of Supervision-of-Supervision form (Appendix B of this application) documenting my successful completion of my Plan of Supervision-of-Supervision will constitute my final application for Approved LMFT Supervisor status.
A. GENERAL INFORMATION
Name:
______________________________________________________
First Middle Last
Home Address:
______________________________________________
Street
___________________________________________
City/State/Zip
Social Security Number: __________________________
Date of Birth: ____________________
Home Telephone: _____________________
First Business Phone ____________________
Second Business Phone _____________________
Cell Phone ________________________
Email Address_____________________________________
Applicant’s Title/Position _______________________________________
Employer or Place of Business: _________________________________
Business Address:
________________________________________________________
Street
________________________________________________
City/State/Zip
Second Work Address, if applicable
______________________________________________________________
Street
___________________________________________________________
City/State/Zip
Check preferred mailing address and LPC Board Website Listing: (___) Home Work (___) First Number; (___) Second Number
Have you ever been denied a professional license and/or certificate? Yes ___ No ___ If yes, state reason:
Are you currently under investigation for any unprofessional/illegal activity? Yes ___ No ___ If yes, state reason:
Has any action been taken to suspend/revoke your license/certification? Yes ___ No ___ If yes, please state date, type of action, name and address of entity taking action:
Have you ever been convicted of a felony? Yes ___ No ___ If yes, please state the felony, date of conviction, 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.
B. PHOTOGRAPH: Applicants not licensed in Louisiana 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. You do not need to provide a recent photograph if you are licensed in Louisiana.
C. CERTIFICATE LETTERING: All applicants please type or print your name how you would like for it to appear on your certificate should you be approved by the Board. DEGREE TITLES, HONORS OR OTHER INFORMATION WILL NOT BE ADDED.
(NAME) _____________________________________________________
D. AFFIDAVIT: Must be notarized.
I, ______________________, being duly sworn, do hereby affirm that I am the person referred to in this application for approval as a Board Approved Licensed Marriage and Family Therapist Supervisor in the State of Louisiana and that all the foregoing statements and enclosures are true in every respect. I affirm that I will inform the LPC Board of Examiners in writing within thirty (30) days if any information that I have provided changes during my tenure as a Board Approved LMFT Supervisor. 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. I also have read the Documentation of Supervision of Supervision form that my supervisor has filled out and sent directly to the LPC Board and certify that the information therein is complete and accurate.
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:______________________
The LPC Board reserves the right to secure further information or evidence that it deems reasonable and proper.
E. LICENSURE AND CERTIFICATION
Please list below your licensure in Louisiana or another state: as a Licensed Marriage and Family Therapist and/or all other professional license(s) to practice counseling, social work, or any other related profession.
____________________________________________________________
Type of License No. Issuing State Expiration Date
____________________________________________________________
Type of License No. Issuing State Expiration Date
In addition to licenses, list any professional certifications:
___________________________________________________________
Type No. Issuing State Expiration Date
F. Education Please list all graduate degrees. List only those graduate degrees that are pertinent to the practice of marriage and family therapy or the ones that you have completed most recently if you have more than three pertinent graduate degrees. If you are a LMFT in Louisiana and have official copies of qualifying transcripts already on file, please write the words "on file" in the first blank below. Duplicate copies are not required.
Name on Transcript _________________________________________________
University/College:______________________________________________________________
Location: ____________________________________Dates Attended: _____________________
Regionally Accredited By: ________________________________________________________
Date of Graduation: ____________Degree: _____________________ Major: _______________
Name on Transcript _________________________________________________
University/College: ____________________________________________________________
Location: ________________________________________ Dates Attended: _______________
Regionally Accredited By: _______________________________________________________
Date of Graduation: ________________Degree: _____________________ Major: ___________
Name on Transcript ________________________________________________
University/College: ______________________________________________________________
Location: ________________________________________ Dates Attended: ________________
Regionally Accredited By: __________________________________________________________
Date of Graduation: _______________Degree: _____________________ Major: _____________
G. DOCUMENTATION OF TRAINING IN MFT SUPERVISION: List the qualifying graduate coursework (or its equivalent, as specified) in the supervision of marriage and family therapy. Applicants for Registered Supervisor Candidate who have not yet completed this coursework must include a plan for its completion as part of their Plan of Supervision-of-Supervision.
Name on Transcript/documentation __________________________________________________
University/College/Granting Organization: ___________________________________________
Address ________________________________________ Dates Attended: ____________________
Name of Course of Study ______________________________________________________________
Graduate Credit Hours Received ___________ CEHs Received _______________
If graduate coursework, institution regionally accredited by:
Didactic Hours __________ Experiential Hours _____________
APPENDIX A
Plan of Supervision-of-supervision for Registered Supervisor Candidates
The proposed supervisor in collaboration with the applying Candidate should fill out this form. Applicants are eligible for approval as Supervisor Candidates after they have completed 2 years experience as a Licensed Marriage and Family Therapist and have completed the necessary coursework in marriage and family therapy supervision or have stated their intent to do so as part of this plan.
This plan should reflect the supervision of the applicant’s supervision of professionally qualified therapists utilizing family therapy techniques in a clinical setting. The plan should further reflect 36 clock hours of face-to-face consultation between the applicant and the proposed supervisor.
NAME OF APPLICANT: ___________________________________________________
PLEASE PRINT or TYPE First/Middle/Last
NAME OF PROPOSED SUPERVISOR: __________________________________________
PLEASE PRINT First/Middle/Last
Professional Address:
______________________________________________
City/State/Zip
Office Phone ______________________
Cell Phone__________________________
e-mail _____________________________
(____)LMFT Board Approved Supervisor? (___) AAMFT Approved Supervisor?
Description of supervision-of-supervision. Describe the frequency and average length of supervision-of-supervision consultation sessions, the setting in which the applicant is supervising and the qualification of the therapists the applicant is supervising, how video/audio tapes are to be used in the supervision-of-supervision process, and how the supervisor is to provide feedback to the applicant about his/her progress. If the applicant has not completed the necessary MFT supervision coursework, use this section to specify when and from what institution the applicant plans to fulfill this requirement. Supervision of supervision must be done face-t0-face in person. Supervision done via video-conferencing, online, or any other electronic method is not acceptable.
Date supervision to begin: ____________
Proposed date of completion: _____________
Goal(s) of supervision-of-supervision. Briefly describe what the applicant plans to learn during the supervision-of-supervision process. This statement should be consistent with the Approved Supervisor’s philosophy of supervision:
I, __________________(Please print or type), the applicant, agree to work under the supervision of _____________________(Please print or type) who is a LA Board Approved LMFT Supervisor. We both agree to work together to fulfill this supervision-of-supervision plan. I, ________________(Please print or type), the proposed supervisor, agree to submit any amendments to this plan to the LPC Board of Examiners for further approval and to provide accurate and timely documentation to the Board on behalf of the applicant at the completion of this plan.
Signature of Supervisor_____________________ Date: _________
Signature of Supervisee_____________________ Date:__________
APPENDIX B
DOCUMENTATION OF SUPERVISION-OF-SUPERVISION
Please have your Board Approved LMFT Supervisor fill out this form is to be filled out and send it directly to the LPC Board.
I, __________________________ (Please print or type your name)
certify that _____________________________(Please print or type name), has successfully completed his/her plan of supervision-of-supervision filed with the LPC Board of Examiners. I therefore recommend him/her for approval as a Licensed Marriage and Therapist Supervisor.
I further certify that the supervision hours documented below reflect a minimum of 36 clock hours spent in face-to-face in person consultation with the applicant in his/her supervision of MFT interns or LMFTs therapists practicing marriage and family therapy. This supervision of supervision was not be done via video-conferencing, online, or any other electronic method.
.
Date supervision began _______________________
Date supervision plan was complete ______________
Hours of supervision-of-supervision ____________
Supervisor’s/Candidate’s comments:
Signature of Approved Supervisor __________________________________
Date _______________
Updated February 2007