STATE OF LOUISIANA

LICENSED PROFESSIONAL COUNSELORS BOARD OF EXAMINERS

8631 Summa Avenue, Baton Rouge LA 70809

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

APPLICATION FOR LICENSED MARRIAGE AND FAMILY THERAPY

GRANDFATHERING PERIOD

Verification of Licensure that meets the grandfathering requirements

Applicant: Please forward this form to the licensing board that regulates the license you are using to document your

degree and supervision requirements

Name of Applicant:___________________________________________________________________________________

Title First Middle Last

Address: ______________________________________________________________________________________

Street City State Zipcode

Discipline_________________________________License # ___________________________

Name of License _______________________________________________________________

Date First Issued ___________________________Expiration Date_______________________

Authorization to release information: I hereby authorize ________________________________________ (Name of Board)

_______________ to release the information requested and furthermore to release any information concerning me as may be deemed reasonably

necessary in the consideration of my application to the Louisiana Licensed Professional Counselors Board of Examiners.

Signature of Applicant_____________________________ Date________________________

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

Verification of Licensure

The applicant signing this form holds a valid license in _________________________________ (Discipline and/or Name of License)

in __________. (State) The license was issued on _____________ and his/her license number is ___________.

The CURRENT minimum degree requirement for this licensure is ______________________. Bachelors', Masters', PhD

The current supervision requirement for this licensure is at least two years of supervised clinical experience and at least 1,000 hours of direct client contact?

YES NO

Has this license ever been restricted, limited, suspended or revoked?

YES NO

Are there any complaints pending against this applicant?

YES NO

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

______________________________________________________________________________

Signature: _______________________________________ Date: ________________________

Title: ______________________________________________

State Board or Agency: _____________________________________________________________

Address:_________________________________________________________________________

Street, P. O. Box City State Zip

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