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Post Doctoral/master Experience Verification Form - Alaska Department Of Community And Economic Development

STATE OF ALASKA

BOARD OF PROFESSIONAL COUNSELORS

POST DOCTORAL/MASTER EXPERIENCE VERIFICATION

(For Examination Applicants Only)

Dear Supervisor:

I am applying for licensure in the State of Alaska as a professional counselor. My application shows that I worked under

your supervision from

I am required to provide evidence of this supervised work to the Alaska Board of Professional Counselors. Please provide

the information required directly to the State of Alaska at the address shown below. Thank you for your assistance.

State of Alaska

Department of Community and Economic Development

Division of Occupational Licensing

Board of Professional Counselors

P.O. Box 110806

Juneau, Alaska 99811-0806

Signature

Printed Name

Address

In accordance with AS 08.29.110(a)(6), I must document that I have been supervised in the practice of professional

counseling performed over a period of at least two years under the supervision of an approved supervisor in accordance

with AS 08.29.210. The supervision must include 3,000 hours of supervised experience, with at least 1,000 hours of

direct counseling with individuals, couples, families, or groups and at least 100 hours of face-to-face supervision by a

supervisor approved in accordance with AS 08.29.210 and in accordance with supervised experience under 12 AAC

62.220. This experience must be completed after having received the degree.

The information below must be completed by the supervisor; it may not be completed by the applicant. Supervision must

be provided by a person who has been approved and certified by the board in accordance with AS 08.29.210 and 12 AAC

62.200. Supervision must be provided by a person who is a professional counselor licensed in the State of Alaska, or is a

licensed clinical social worker, licensed marital and family therapist, licensed psychologist, or licensed psychological

associate, licensed physician, or licensed advanced nurse practitioner who is certified to provide psychiatric or mental

health services.

, did supervise

(Name of Supervisor)

(Name of Applicant)

(Name of Institution/Professional Clinic, etc.)

during the period from

Total hours of supervised experience:

Total hours of direct counseling with individuals, couples, families, or groups:

Total hours of face-to-face supervision provided:

The board believes a license to practice professional counseling carries important responsibilities. Please comment, as

supervisor, on the applicant’s qualifications, abilities, character, etc., which involve use of professional counseling as

defined 08.29.490(1)(A)(B)(C).

08-4403c (Rev. 11/99)

Post Doctoral/master Experience Verification Form - Alaska Department Of Community And Economic Development