Date Approved_________
LOUISIANA
LICENSED PROFESSIONAL COUNSELORS
BOARD OF EXAMINERS
MFT INTERN REGISTRATION OF SUPERVISION SECTION 1:
MEETING ACADEMIC REQUIREMENTS
INSTRUCTIONS:
You may register as a marriage and family therapy intern by using SECTION 1 of the registration form as soon as you have completed the educational requirements specified by the board. Complete SECTION 2 PRACTICE SETTING when you secure the setting where you will obtain your supervised hours and send it to the board office. Complete SECTION 3 SUPERVISION AND SUPERVISED EXPERIENCE PLAN after you secure a supervisor and send it to the board office. You may not practice marriage and family therapy or begin to count supervision hours until all three parts 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.
ACADEMIC/PRACTICUM/INTERNSHIP REQUIREMENTS
(Please check one of the three options)
_____ I have graduated from a marriage and family therapy program accredited by the Commission on Marriage and Family Therapy Education (COAMFTE).
_____ I have graduated from a marriage and family counseling program accredited by the Council on Counseling and Related Educational Programs (CACREP) and have a minimum of six courses in marriage and family counseling.
_____ I am applying to meet COAMFTE equivalency standards. You must fill out the TRANSCRIPT FORM for Specific Equivalency Requirements That Meet the Standards for Marriage and Family Therapy Established by COAMFTE as Determined by the Advisory Committee and Approved by the LPC Board and will need to include documentation as needed if the title of the course does not clearly explain how it fits into a content area. See §3311(A) and (B) for specifics. A COAMFTE and Advisory Committee approved MFT practicum is required but does not count as coursework. You cannot practice in Louisiana outside of an academic setting unless you are registered as an intern with a licensing board or are licensed as a mental health professional. You would not have to be on campus but your supervision would have to be done as a part of your educational requirements.
All applicants must send the following to the board office to register as a MFT intern:
* Official graduate transcript(s) must be forwarded directly from each college or university to the Board office. You do not need transcripts for undergraduate degrees or graduate degrees unrelated to marriage and family therapy or another mental health clinical disciplines.
* FEE: Please include appropriate fee in the form of a Money Order, Cashier's Check or Certified Check for $100.00. FEES ARE NON-REFUNDABLE.
* (PERSONAL CHECKS WILL BE SENT BACK)
* 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 Website www.lpcboard.org
APPLICANT DATA
Name: ______________________________________________________________
Current Residence
____________________________________________________________________
City/State/Zip _________________________________________________________
Mailing Address to use on LPC Website
_____________________________________________________________________
City/State/Zip __________________________________________________________
Home Phone _______________ Business Phone _______________
Email _________________ Social Security Number _____________
Date of Birth ______________ Place 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.
Education:
Name on Transcript if different from now__________________________________________
University/College _________________________________________________________
Location _________________________________________________________
Institution Regionally Accredited by_____________________________
Other Accreditation (e.g., program) (Please specify_________________
________________________________________________________
Dates Attended _______________Date of Graduation ______________
Degree ____________ Major _________________________________
Hours in Degree ________________
THE BOARD MEETS THE THIRD FRIDAY OF MOST MONTHS, BE SURE TO CHECK THE WEBSITE FOR ANY CHANGE OF DATES.
COMPLETE APPLICATIONS MUST BE IN THE BOARD OFFICE BY THE SECOND FRIDAY OF THE MONTH OR IF DATE HAS CHANGED THE FRIDAY BEFORE THE BOARD MEETING.
Updated February 2007