STATE OF LOUISIANA

LICENSED PROFESSIONAL COUNSELORS BOARD OF EXAMINERS

8631 SUMMA AVENUE

BATON ROUGE, LOUISIANA 70809

DOCUMENTATION OF EXPERIENCE FOR LICENSE AS A PROFESSIONAL COUNSELOR

INSTRUCTIONS: The applicant for license is to complete Section I of this form and the supervisor is to complete Section II. Please type or print. This form may be photocopied if needed.

SECTION I (TO BE COMPLETED BY APPLICANT)

Dear _____________________________________________(Name of Supervisor):

I am applying for a license to be issued by the Louisiana Professional Counselors Board of Examiners. To validate the experience required of me to obtain a license, the members of the Board would appreciate your providing them with information regarding my counseling experience. I hereby consent to the release of any information, favorable or otherwise, which you may have concerning my employment or my practice. Please return the completed form directly to the Louisiana Board at the above address.

Applicant's Signature: ______________________________ Date: _____________________________

Applicant's Full Name:_________________________________________________________________

Mailing Address: _____________________________________________________________________

___________________________________________________________________________________

Home phone: ______________________                Work phone: _____________________________________

E-mail: ______________________________________________________________________________

Name of setting(s)  in which internship took place: _____________________________________

________________________________________________________________________

Dates of supervision:  from (MO/YR)__________ to (MO/YR)__________ (Must be at least 2 full years).

Total Hours:   Direct client contact hours__________      Indirect hours_________

Total number of face-to-face hours with supervisor _________

Total numbers of hours of supervised experience _________

SECTION II (TO BE COMPLETED BY APPLICANT'S SUPERVISOR)

THIS FORM IS TO BE SUBMITTED TO THE LPC LICENSURE BOARD AT THE COMPLETION OF THE SUPERVISORY PERIOD OR IF THERE IS A CHANGE IN SUPERVISORS.

Supervisor's Full Name: ___________________________________________________________

Address:_________________________________________________________________________

                _________________________________________________________________________

Telephone:  (H) _________________________________  (W) ______________________________

E-mail ___________________________________________________

III.     AREAS OF EVALUATION (TO BE COMPLETED BY SUPERVISOR) :

Circle the number that most nearly approximates the supervisee's skill level

    1- Unsatisfactory     2- Below Average     3- Average      4- Above Average      5- Superior

1. Exhibits knowledge counseling theories:                                                      1          2          3          4          5
              
2. Ability to conceptualize cases:                                                                       1          2          3          4          5

3. Knowledge and use of appropriate techniques:                                          1          2          3          4          5

4. Ability to develop therapeutic alliance with clients:                                   1          2          3          4          5

5. Exhibits appropriate communication skills:                                                   1          2          3          4          5

6. Exhibits appropriate assessment skills:                                                         1          2          3          4          5

7. Exhibits intervention skills:                                                                             1          2          3          4          5

8. Exhibits qualities of the professional self:                                                    1          2          3          4          5

9. Demonstrates knowledge and practice of LPC rules and ethics:              1          2          3          4          5

 Briefly describe your experience in working with the supervisee applying for licensure:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

As the supervisor of the applicant's counseling experience, do you recommend this person for licensure?

              ________ YES               ________ NO

If no, please explain in detail on a separate sheet.

I HAVE REVIEWED THE APPLICANT'S DOCUMENTATION OF EXPERIENCE IN SECTION I OF THIS FORM AND THE REPORTED HOURS IN EACH CATEGORY.

      _____ARE   _____ARE NOT SUBSTANTIALLY CORRECT.

Supervisor Signature _____________________________________________  Date _________________

 Supervisees Signature ___________________________________________   Date __________________

The LPC Board encourages all supervisors to review the information contained in this evaluation with the supervisee prior to submitting it to the Board.