Ky Lpcc Online License PDF Details

The Ky Lpcc online license form is a great way to renew your license if you are a licensed professional clinical counselor in the state of Kentucky. The process is quick and easy, and you can complete it from the comfort of your own home. Just be sure to have all of your information ready beforehand, including your license number and date of birth. Once you have submitted the form, you will receive an email confirmation with further instructions.

Below is the information in regards to the form you were in search of to fill out. It can tell you the span of time you'll need to fill out ky lpcc online license, what parts you will have to fill in and a few other specific details.

Form NameKy Lpcc Online License
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other nameslpcc license verification ky, ky lpcc renewal, lpca ky license renewal, kentucky lpcc license verification

Form Preview Example

2011 Edition


PO BOX 1360



Your Licensed Professional Clinical Counselor credential expires on October 31, 2011. In accordance with KRS 335.535 and regulations (201 KAR 36:020) governing this profession, you are required to renew your license annually with the transmittal of this form and a renewal fee of $150.00, (check or money order) made payable to the Kentucky State Treasurer. Please return this completed form with the fee to the address above prior to the deadline date of October 31,2011. The fee for renewals received during the 60 day grace period is $25.00. Credentials not renewed prior to December 31,2011 will be terminated and you must immediately CEASE AND DESIST (no exceptions) the use of the title Licensed Professional Clinical Counselor in Kentucky.

If your renewal reminder indicated that you had been selected for AUDIT please send copies of evidence of having completed 10

hours of continuing education as defined in 201 KAR 36:030.





Present place of employment




















Home telephone number



Business telephone #


Home e-mail address



Business e-mail address



License number



Social Security Number






(Please complete hack page ofrenewalform)

2011 Edition

1. Have you been convicted of a felony since your last application or renewal? “Conviction” including all instances in

which a plea of no contest is the basis of the conviction.






If yes, list offense and provide details on a separate sheet of paper.






2. Have you been subject to disciplinary action by a mental health credentialing board?





) Yes

If yes, give details on a separate sheet of paper.






3.List any state in which you have become licensed or certified since your last renewal, the type of license or certification, and the number of the certification or license:

4. Are you currently serving in the military? (

) No


) Yes

5.If you are currently eligible to supervise LPCA’s please provide date of completion of required supervision training: Date of Board Approved Supervision Training


I do certify under penalty of law that the information contained herein is true, correct, and complete to the best of my knowledge and belief. I am aware that, should investigation at any time disclose any such misrepresentation or falsification, my license could be subject to disciplinary action by the Kentucky Board of Licensed Professional Counselors

I have completed

hours of continuing education during the annual period for renewal as defined in 201 KAR 36:030.

If your renewal application indicates that you have been selected for AUDIT please send copies of evidence ofhaving completed 10

hours ofcontinuing education as defined in 201 KAR 36:030.



/________ /________


(Sign your name - Do not print or type)


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filling out ky board lpcc part 1

Fill out the Address, City, Address, State, Zip, City, State, Zip, Home telephone number, Business telephone, Home email address, Business email address, License number Social Security, and Please complete hack page of space using the data demanded by the application.

Filling out ky board lpcc stage 2

It is vital to put down particular information inside the area Have you been convicted of a, which a plea of no contest is the, Have you been subject to, If yes give details on a separate, Yes, List any state in which you have, certification and the number of, Are you currently serving in the, Yes, If you are currently eligible to, Date of Board Approved Supervision, CERTIFICATE OF COMPLIANCE, and I do certify under penalty of law.

stage 3 to filling out ky board lpcc

Explain the rights and responsibilities of the parties in the space I do certify under penalty of law, I have completed, hours of continuing education, If your renewal application, Signature, Sign your name Do not print or, and Date.

Entering details in ky board lpcc stage 4

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