Update Contact Information Form printable pdf download

UPDATE your contact information with WVBEC - LPC or LMFT

(Circle one)

Per Series 1, LPC Licensing Rule, Section 12.2 A licensee shall notify the Board within thirty (30) days

of any change of his or her legal name, primary address, telephone number, email address or similar

change of location or status.

Check here if your legal name has changed AND include a copy of the appropriate court documents

along with the $5 processing fee, per Series 2, Fee Rules.

Check here if you are requesting a license replacement document, AND include the fee of $10, per

Series 2, Fee Rules.

Check here if your employer has changed. Please also complete and include a copy of the Professional

Disclosure Form. Fillable form can be found on our website at the Popular Forms tab/LPC forms. The

original will need to hang next to your license certificate.

Check here to update your contact information with the information included below. Thank you.

Name: ____________________________________________________________________

First

Middle

Last

Primary Email address: _______________________________________________________

Home Address: ______________________________________________________________

Box or Street Number

City

State

Zip Code

Home phone:

(_____) ________ - ________ County of Residence: __________________

Employer: ___________________________________________________________

Employer Category

Private Practice

Non-Profit Agency

Profit Agency

Hospital

Federal or State Agency

College or School

Other _____________

Position: _________________________________________

Address: __________________________________________________________________

Box or Street Number

City

State

Zip Code

Work phone (_____) ________ - _______County of Employer: ________________________

Please check other CURRENT Licenses, Credentials, and/or Certifications you hold

ALPS

LPC

LMFT

School Counselor

____________________ ______________________

National Certified Counselor

Certified Rehabilitation Counselor

Certified Addictions Counselor

WV Social Work License

TSW

LSW

LCSW

LICSW Expiration Date ______________

WV Psychology License

Supervised

Clinical

School Expiration Date _____________

Are you an active member of ACA _______ Are you an active member of AAMFT?_________________

Are you an active member of NBCC________

Mail completed form and fee, if applicable, to:

WVBEC, 815 Quarrier Street, Suite 212, Charleston, WV 25301

Update Contact Information Form

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