Form 08-4403 - Professional Counselor Licensure Application - Juneau - 2013 Page 15
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18STATE OF ALASKA
BOARD OF PROFESSIONAL COUNSELORS
POST DOCTORAL/MASTER EXPERIENCE VERIFICATION
(For Examination Applicants Only)
Name of Supervisor (print):
I am required to provide evidence of this supervised work experience to the Alaska Board of Professional Counselors.
Please provide the information required and return completed form to:
State of Alaska
Department of Commerce, Community, and Economic Development
Division of Corporations, Business and Professional Licensing
Board of Professional Counselors
P.O. Box 110806
Juneau, Alaska 99811-0806
Applicant Signature:
Applicant Printed Name:
Applicant’s Address:
Note: Print or type legibly.
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 my 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.
I,
, did supervise
(Name of Supervisor)
(Name of Applicant)
at
(Name of Institution/Professional Clinic, etc.)
during the period from
/
/
to
/
/
.
(mm/dd/yyyy)
(mm/dd/yyyy)
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 the use of professional counseling as
defined 08.29.490(1)(A)(B)(C).
( Rev. 03/04/13)
Page 15
08-4403c
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