STATE OF LOUISIANA:  LICENSED PROFESSIONAL COUNSELORS BOARD OF EXAMINERS                    

 License No. __________________________ Issue Date ___________________________       

A. INSTRUCTIONS:

1. All sections must be completed. Type or print clearly. If additional information is needed for any questions, please attach a separate sheet.

2. Official graduate transcript(s) must be forwarded directly from college or university.

3. Documentation of Experience forms must be forwarded directly from supervisor(s).

4. FEE: Please include appropriate fee in the form of a Money Order, Cashier's Check, or Certified Check. (FEES ARE NONREFUNDABLE).

5. Declaration of Practices and Procedures

6.  Read Chapter 7 of the rules for Louisiana Licensing Requirements.

7. Mail completed application to the following address:

8. Copy of your file if you are licensed in another state (sent directly from state board).

Louisiana Licensed Professional Counselors Board of Examiners

8631 Summa Avenue, Suite A

Baton Rouge, Louisiana 70809

Telephone (225) 765-2515   FAX (225) 765-2514

B. GENERAL INFORMATION

                 Dr.

1. Name:   Mr. _______________________________________________________________________________

                Ms.

2. Current Residence: ___________________________________________________________________________________________

   __________________________________________________________________________________________________________

  City/State _________________________________________________Zip______________________________

3. Place of Employment ______________________________________________________________________

    Address_________________________________________________________________________________

    City/State ________________________________________________Zip _____________________________

4. Which address to you prefer to be used for correspondence _____ Home   _____ Work

    Which address do you prefer to be put on the LPC Website   _____ Home  _____ Work

 5.  Email Address ____________________________________________________________________________

6. Home Telephone: ( ________) ______________________________ Business Telephone: (________)__________________________

7. Exam Score: ________________    8: Date Exam was taken: _______________________________ MO/DAY/YR

10. Social Security Number: ____________________________________________________________

11. Date of Birth: ______________________________

12. Place of Birth: _____________________________________________

13: A Registration of Supervision form is on file at the LPC Board office? _____ Yes, _____ No.

14. Employer or Place of Business: ____________________________________________________________________________

15. Have you ever applied for this license before? _____ Yes, _____ No

16. Have you ever been denied a professional license and/or certificate? _____ Yes, _____ No. If yes, state reasons on an attached sheet.

17. Are you certified by a national counseling certifying agency? _____ Yes,_____ No. If Yes, give certification numbers and

Name and address of the certifying agencies. ___________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

18. Do you possess or have ever possessed a professional license(s) or certificate(s) to practice counseling or related

profession by Louisiana and/or any other state? _____ Yes, _____ No. If Yes, give license or certificate

number(s), title(s), and state(s) issuing the license(s) or certificate(s). _________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

19. Has action been taken to suspend/revoke your license/ certificate? _____ Yes, _____ No. If Yes, state date and type of

action; name and address of entity taking such action._____________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

20. 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 the separate attached sheet.

C. EDUCATION

Official transcripts must be sent directly to the Board from the granting institution to validate the information in this

section. Only those transcripts containing the degree and coursework used to meet the licensure requirement need

be sent. If more space is needed, use additional sheets supplying the same type of information.

Name on transcript if different from B.1.: ______________________________________________________________

University/College: _________________________________________________________________________________

Location: ___________________________________ Accredited By:____________________________________________

Dates Attended: ___________________________ Date of Graduation: __________________________________

Degree: ________________________ Major: ________________________ Hours in Degree: _________________

D. PROFESSIONAL COUNSELING EXPERIENCE

List below the experience you claim as qualifying experience for obtaining a license. If more space is needed, use additional

sheets supplying the same type of information.

1. Name of Employing Agency or Person: _____________________________________________________________

Address of employer: _____________________________________________________________________________

______________________________________________________________________________________________

Immediate Supervisor: ____________________________________________________________________________

Employment Date: From _________________________ To___________________________ Hours per week ______

Your Employment / Job Title: _____________________________________________________________________

Brief Description of Your Job Duties: ________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

2. Name of Employing Agency or Person: ____________________________________________________________

Address of employer: ____________________________________________________________________________

_____________________________________________________________________________________________

Immediate Supervisor: ___________________________________________________________________________

Employment Date: From _________________________ To___________________________ Hours per week ______

Your Employment / Job Title: _____________________________________________________________________

Brief Description of Your Job Duties: ________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

3. Name of Employing Agency or Person: ____________________________________________________________

Address of employer: ____________________________________________________________________________

_____________________________________________________________________________________________

Immediate Supervisor: ___________________________________________________________________________

Employment Date: From ______________________ To________________________ Hours per week ___________

Your Employment / Job Title: _____________________________________________________________________

Brief Description of Your Job Duties: ________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

E. NBCC EXAM SCORES-All applicants must provide an NCE score sent directly from NBCC.

   (Unless exam was taken through the LPC Board office.)

F. 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.

G. LICENSE LETTERING - Please type or print your name below how you would like for it to appear on your license,

should you be approved by the Board. Degrees, titles, honors or other information will not be added.

_________________________________________________________________________________________

H. AFFIDAVIT - Must be signed in presence of notary.

     I, the below named applicant, being duly sworn, do hereby affirm that I am the person referred to in this application

for a license to practice mental health counseling as a Licensed Professional counselor 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 the license to practice

mental health counseling in the State of Louisiana.

The Board of Examiners reserves the right to secure further evidence that it deems reasonable and proper from the sources above.

Enclosed in the application fee of $200.00 made payable to the Licensed Professional Counselors Board of Examiners,

WHICH IS NON REFUNDABLE, in the form of a money order, cashier's check, or bank draft .

PERSONAL CHECKS ARE NOT ACCEPTED.

State of Louisiana

Parish of _______________________________________________________

Applicant Signature ______________________________________________ Date: _____________________________

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 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.