State of Louisiana

LICENSED PROFESSIONAL COUNSELORS BOARD OF EXAMINERS

8631 SUMMA AVENUE, BATON ROUGE, LA 70809

Phone: 225-765-2515         Fax: 225-765-2514

Website: www.lpcboard.org

VERIFICATION OF AAMFT APPROVED SUPERVISOR

OR AAMFT APPROVED SUPERVISOR CANDIDATE STATUS [Updated February 2007]

Applicant: Please forward this form to AAMFT

Name of Applicant ___________________________________________________

Title             First                       Middle                     Last

Address:___________________________________________________________

 Street          City                                           State                               Zip

AAMFT ID #: ___________

Authorization for release of information: I hereby authorize the American Association for Marriage and Family Therapy to release the information requested and furthermore to release any additional information concerning me as may be deemed reasonably necessary in the consideration of my application for LMFT Approved Supervisor or Registered Supervisor Candidate to the Louisiana Licensed Professional Counselors Board of Examiners. 

Signature of Applicant: __________________________Date: _____________

****************************************************

Verification of Approved Supervisor Status by

 The American Association for Marriage and Family Therapy

This to certify that the applicant signing this form was issued Member number__________ on [date]________________ and is a current Clinical Member.

Date approved as AAMFT Approved Supervisor ___________, or

Date approved as AAMFT Approved Supervisor Candidate ________________

Has this applicant ever been found in violation of the AAMFT Code of Ethics?

 (___) Yes        (___) No

Has this applicant's membership ever been restricted, suspended, or revoked?

 (___) Yes        (___) No

Is this applicant under investigation for alleged violation(s) of the AAMFT Code of Ethics?

 (___) Yes        (___) No

Please be specific about any disciplinary action taken against this applicant:

_______________________________________________________________

_______________________________________________________________

Person Verifying: _________________________________________________

Signature                                                       Title

Please return this form directly to the LPC Board at the address at the top. Thank you.