Documentation Of Supervised Counseling Experience - New Jersey
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1
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3New Jersey Office of the Attorney General
Division of Consumer Affairs
State Board of Marriage and Family Therapy Examiners
Professional Counselor Examiners Committee
124 Halsey Street, 6th Floor, P.O. Box 45044
Newark, New Jersey 07101
(973) 504-6582
Documentation of Supervised Counseling Experience
(This form should be completed by the supervisor and forwarded directly to the Committee.)
for:
Licensed Professional Counselor Candidate
Licensed Rehabilitation Counselor Candidate
Please print clearly.
Information about the applicant
____________________________________________________________________________________________________
Last name
First name
Middle initial
Maiden name (if applicable)
____________________________________________________________________________________________________
Street address
City
State
ZIP code
__________________________________________________
_ _____________________________________________
Telephone number (include area code)
E-mail address
Information about the supervisor
____________________________________________________________________________________________________
Last name
First name
Middle initial
Maiden name (if applicable)
____________________________________________________________________________________________________
Street address
City
State
ZIP code
__________________________________________________
_ _____________________________________________
Telephone number (include area code)
E-mail address
Please note: The supervisor must hold a clinical license in a mental health-related discipline.
Qualified supervisor: N.J.A.C. 13:34-10.2 and 13.1(a) (Check all that apply.)
ACS (NBCC-Issued)
Three (3) graduate credits: Clinical Supervision
Other: _____________________
(Attach official verification for area(s) you checked.)
1. Do you hold a clinical mental health-related professional license in the State of New Jersey? Yes No
If “Yes,” check the appropriate box.
Psychiatrist
Marriage and Family Therapist
Rehabilitation Counselor
Psychologist
Professional Counselor
Clinical Social Worker
Other: _________________________________________________
Year licensed: _______________
License number: __________________
2. Do you hold a professional license in any other state, the District of Columbia or in any other jurisdiction?
Yes No
If “Yes,” check the appropriate box.
CoNtACt the IssuINg lICeNsINg boArd to obtAIN AN offICIAl letter of good stANdINg.
Psychiatrist
Marriage and Family Therapist
Clinical Social Worker
Physician
Rehabilitation Counselor
Other: ________________________
Professional Counselor
Psychologist
Year licensed: _______________
License number: __________________
State of licensure: _______________
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