STATE
OF LOUISIANA
Issue Date
___________________
Licensed Professional Counselors Board of Examiners
License # ____________________
GRANDFATHERING APPLICATION FOR: LICENSED
MARRIAGE AND FAMILY THERAPIST
General Instructions for Application
Please CHECK the option under which you are applying:
_______ Option 1. Applicants
who hold CURRENT CLINICAL MEMBERSHIP IN THE AMERICAN ASSOCIATION FOR MARRIAGE
AND FAMILY THERAPY (AAMFT) must complete all sections except B (Education),
and C (supervised clinical experience). Attach your Statement of Practice, and
send the Verification of AAMFT Membership Form to AAMFT.
_______ Option 2. Applicants
who wish to apply by documenting your educational and supervised clinical
experience must complete the entire application and attach your Statement of
Practice. Official graduate transcript(s) must be forwarded directly from
colleges and universities and a letter verifying the hours of supervised
clinical experience must be sent directly from supervisors. The director
of a degree program may write a letter directly sent that verifies supervised
clinical practice received in a degree program after the qualifying Master's
degree was granted.
_______ Option 3. Applicants
CURRENTLY LICENSED IN MENTAL HEALTH COUNSELING IN LOUISIANA already have
documentation on file in the LPC Board of Examiners office need to complete
ONLY Sections A, E, (the way you want your name to appear on license), and F
attach your Statement of Practice.
_______ Option 4. Applicants
who hold CURRENT LOUISIANA LICENSES IN ALLIED MENTAL HEALTH DISCIPLINES
WHOSE REQUIREMENTS SUBSTANTIALLY MEET THE GRANDFATHERING REQUIREMENTS TO BECOME
A LICENSED MARRIAGE AND FAMILY THERAPIST must complete all sections except B
(Education), and C (supervised clinical experience). Attach your Statement of
Practice, and send the Verification of Licensure Form to your licensing
board.
_______ Option 5. Applicants
who hold CURRENT LICENSES IN OTHER STATES IN MARRIAGE AND FAMILY THERAPY,
MENTAL HEALTH COUNSELING, AND OTHER ALLIED MENTAL HEALTH DISCIPLINES WHOSE
REQUIREMENTS SUBSTANTIALLY MEET THE REQUIREMENTS FOR LICENSED MARRIAGE AND
FAMILY THERAPY must complete all sections except B (Education), and C
(supervised clinical experience). Attach your Statement of Practice, and send
the Verification of Licensure Form to your licensing board.
SPECIFIC INSTRUCTIONS:
1. The
licensing Requirements are posted at www.lpcboard.org under FORMS.
2. Complete
sections as directed in General Instructions. Type or
print clearly.
If additional information is needed for any sections, please attach 8 1/2
X 11 sheets continuing in the same format as that used in the application.
3. Guidelines
and rules for writing a Statement of Practice and a sample are posted at
www.lpcboard.org under FORMS.
4. FEE: Please
include appropriate fee in the form of a Money Order, Cashier's Check, or
Certified Check. (FEES ARE
NONREFUNDABLE)
5. Mail the
completed application to the following address:
Louisiana Licensed Professional
Counselors Board of Examiners
8631 Summa Avenue, Baton Rouge, LA 70809
Telephone (225) 765-2515 FAX
(225) 765-2514
A. General
Information
Name:
Dr., Mr,
Ms.:_____________________________________________________________________________
(First)
(Middle)
(Last)
Home
Address:
(Street)____________________________________________________________________
(City)______________________________________(State)__________________(Zip)_______
Work
Address:
(Street)_______________________________________________________________________
(City)______________________________________(State)____________________(Zip)______
Check preferred mailing address
and LPC Board Website Listing:
(____)Home
(____)Work
Home Telephone: (
)______________________
Business Telephone: (
) _____________________
Email Address:
_________________________________________________________________________________
Social Security Number:
_________________________________
Date of Birth: ________________________
Place of Birth: (City)
___________________________________ (State)
____________
(Zip) __________________
Employer or Place of Business:
_____________________________________________________________________
Address: (Street)
________________________________________ (State) ____________ (Zip)
__________
Have you ever been denied a professional license and/or certificate: Yes ___ No ___ If yes, state reason:
______________________________________________________________________________________________
______________________________________________________________________________________________
Do you presently possess a
professional license(s) or certificate(s) to practice counseling or related
profession issued in Louisiana or another State?
Yes _____
No _____
If yes, please give:
Title License Number(s) Issuing State Expiration Date:
Title
License
Number(s)
Issuing State
Expiration
Date:
Title
License
Number(s)
Issuing State
Expiration
Date:
Are you currently certified by a
national agency or organization? Yes
_____
No _____ If yes,
please give:
Title Certificate Number(s) Issuing Organization Expiration Date:
Title
Certificate
Number(s)
Issuing
Organization
Expiration
Date:
Title
Certificate
Number(s)
Issuing
Organization
Expiration
Date:
Has any action been taken to suspend/revoke your license/certification? Yes _____ No _____ If yes, please state date and type of action: name and address of entity taking such action: ________________________________________________________________________________________________
_________________________________________________________________________________________________
Have you ever been convicted of
a felony?
Yes _____
No _____
If yes, please state the felony, date of conviction, name, 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.
EDUCATION
Name on Transcript if different from that used to apply: ______________________________________________________
University/College: _________________________________________________________________________________
Location: ________________________________________ Dates
Attended: ____________________________
Regionally Accredited By:
_____________________________________________________________________
Date of Graduation: _____________Degree:
_____________________ Major: ________________
Name on Transcript if different
from that used to apply:
_______________________________________________________
University/College:
__________________________________________________________________________________
Location: ________________________________________ Dates
Attended: _____________________________
Regionally Accredited By:
______________________________________________________________________
Date of Graduation:
_____________Degree: _____________________ Major: _________________
Name on Transcript if different from that used to apply: _______________________________________________________
University/College:
__________________________________________________________________________________
Location: ________________________________________ Dates
Attended: _____________________________
Regionally Accredited By:
______________________________________________________________________
Date of Graduation:
_____________Degree: _____________________ Major:
________________
Name on Transcript if different from that used to apply: _______________________________________________________
University/College:
__________________________________________________________________________________
Location: ________________________________________ Dates
Attended: _____________________________
Regionally Accredited By:
______________________________________________________________________
Date of Graduation:
______________Degree: _____________________ Major: _________________
C. SUPVERISED
CLINICAL EXPERIENCE after the receipt of the qualifying degree:
Please list supervised clinical experience after the receipt of your qualifying degree in the practice of mental health
discipline. A minimum of
two years is required for licensure. (Use
additional sheets if needed.)
Dates
Organization or Site
Your Title
Name
of Supervisor
Hours
_________
_______________________
_____________________
____________________
_________
_________
________________________
_____________________
____________________
_________
_________
________________________
_____________________
____________________
_________
_________
________________________
______________________
____________________
_________
_________
________________________
______________________
____________________
_________
D.
PHOTOGRAPH: All
applicants 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.
E. LICENSE
LETTERING:
Please type or print your name how you would like for it to appear on
your license should you be approved by the Board. DEGREE
TITLES, HONORS OR OTHER INFORMATION WILL NOT BE ADDED.
(NAME)
___________________________________________________________________________________________
F.
AFFIDAVIT: Must be
signed in presence of a notary.
I, the below named applicant,
being duly sworn, do hereby affirm that I am the person referred to in this
application for licensure as a Licensed Marriage and Family Therapist in the
State of Louisiana, and that all foregoing statements and enclosures are true in
every respect.
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.
The LPC Board reserves the right
to secure further evidence that it deems reasonable and proper from the sources
above.
Enclosed in the application is
$200.00 made payable to the Licensed Professional Counselors Board of Examiners,
WHICH IS NON REFUNDABLE in the form of money order, cashier's check, or
bank draft.
PERSONAL CHECKS NOT ACCEPTED.
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:______________________
NOTE: The LPC
Board meets the third Friday of most months. Be
sure to check our website for meeting dates. All
materials for review must be in the board office the Friday before the
meeting.