License Verification Form - Counselors
Download a blank fillable License Verification Form - Counselors in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete License Verification Form - Counselors with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1License Verification Form
The applicant is required to complete Section I of this form and forward to the current licensing board for completion of
Section II. The current licensing board should mail to the address listed above.
Section I. To be completed by Applicant
Applicant’s Name ____________________________________________________________________________________________
Last
First
Middle
Applicant’s SS# ________-_____-________
Applicant’s License #__________________
State of Issue ______________
Years of Experience as an LPC __________
Date issued ___________
Type of License ______________________
Academic Institution ________________________________________________________________________________
Degree ___________________________________________
Year Conferred __________
Credits Earned __________
I hereby authorize the release of licensure information to the North Carolina Board of Licensed Professional Counselors.
__________________________________________________________
_________________________
Applicant’s Signature
Date
Section II. To be completed by the State Licensing Board where the North Carolina applicant is currently licensed
Title of License _____________________________________________________________________________________
Does this license require supervision in order to practice?
___ Yes ___No
License status:
___ Active or
___Inactive
Issue date _____________________
Expiration date __________________
mm/dd/yyyy
mm/dd/yyyy
Is this license in good standing?
___ Yes ___No If not, attach explanation.
License issued by:
___ Examination: ___ NCE
___ NCMHCE
___ CRC ___ Other ______________________________
___ Endorsement
From what state? ______________________________
___ Grandfathering
Supervised post-degree experience:
Total # of hours required _______________ ___
Supervisor license/credentials required __________________________
Total direct counseling hours _______________
Total indirect counseling hours _________________
Total individual supervision hours per week ___________
Total group supervision hours per week ___________
Date range of experience:
From: ______________________
To: ____________________________
mm/dd/yyyy
mm/dd/yyyy
Is there any record of disciplinary action taken against this licensee? ___ Yes ___No If yes, attach an explanation.
Do you require verification of continuing education for licensure renewal?
___ Yes ___No
# of contact hours required _______
# of years in renewal period _______
# of ethics hours required _______
Board Name ______________________________________________________________________________________________________
________________________________________________________________________________________________________________
Address
City/State/ZIP
__________________________________________
________________________________________
(State Seal)
Signature of person completing form
Printed name of person completing form
__________________________________________
________________________________________
Official Title
Date form completed
This version supersedes all previous versions
Revised 01/17/2017
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal