Lgpc Application Form – Fill Out and Use This PDF

LGPC APPLICATION INSTRUCTIONS

1.APPLICATION: - Applications are to be typed or printed legibly. All questions on the application must be answered. Please read through the application form carefully before filling out application.

* All documentation must be original, on the forms currently in use by the Board and submitted as a complete application packet;

*Documentation containing white out or corrections will not be accepted by the Board.

2.FEE: Application fee of $75.00 must be included with the application. Make your check payable to the Board of Professional Counselors and Therapists. FEES ARE NON-REFUNDABLE.

3.OFFICIAL TRANSCRIPT(S): Please have your college send your official transcript(s) directly to you in a sealed envelope. Send your sealed official transcript(s), the application, and the application fee to the Board in ONE packet. Please do not have the college or university mail the official transcript directly to the Board.

The official seal of the college or university is required on all official transcripts with the date the degree was awarded/conferred.

4.EDUCATION: – Applicants must hold a master’s degree with a minimum of 60 graduate semester credits or 90 graduate quarter credits. For Doctoral Degree holders, 90 graduate credits or 135 graduate quarter credits.

For both the Masters and Doctorate degree applicants must have a minimum of three (3) graduate semester credit hours or five (5) graduate quarter credits in each of the following core courses:

Human Growth and Development

Social and Cultural Foundations of Counseling

Counseling Theory

Counseling Techniques

Group, dynamics, processing and counseling

Lifestyle and Career Development

Appraisal of Individuals

Research and Evaluation

Professional, Legal and Ethical Responsibilities

Marriage and Family Therapy

Supervised Field Experience

Alcohol and Drug Counseling

Diagnosis and Psychopathology

Psychotherapy and Treatment of Mental Emotional Disorders

5.EXAMINATION:

a.To become licensed by the Board applicants must pass the NCE of the NBCC and the Maryland Law Test.

b.After your application is received, reviewed and approved by the Maryland Board of Professional Counselors and Therapists you will be notified that you are approved to sit for the National Counselor Examination (NCE) and Maryland Law Test.

The National Board of Certified Counselors (NBCC) will be notified of your eligibility and you will be sent an examination registration form from the Board. Please go to our website, www.dhmh.state.md.us/bopc for current examination dates. The NCE is now Computer Based and is administered on the first full week of each month. The Maryland Law test is administered at the Board’s office, twice monthly.

6.GRADUATE PROFESSONAL COUNSELOR: A licensed graduate professional counselor may practice graduate professional counseling for 2 years under the supervision of an approved supervisor while fulfilling the 2-years post graduate supervised clinical experience requirement.

7.RENEWAL: The Board may renew a graduate license for 2 years upon written request for renewal. In order to process your renewal in a timely manner, the request must be submitted two (2) months before the graduate license is due to expire.

In order to renew the graduate license the following is required:

Submit a completed renewal application;

Ensure that all Maryland State Taxes and Unemployment Insurance Contributions have been paid;

Pay the $200.00 renewal fee, plus, the Maryland Health Care Commission fee ;

 Submit documentation of continuing education hours (40 hours for 2-year extension, 20 hours of Category A for 1-year extension).

Please call the Board staff to request the necessary paperwork

Mail all of the above to:

Board of Professional Counselors and Therapists

4201 Patterson Avenue – Suite 316

Baltimore, Maryland 21215

MARYLAND APPLICATION FOR LICENSED GRADUATE PROFESSIONAL COUNSELOR

FOR OFFICE USE ONLY

LICENSE NUM/DATE:_______________________

EPPP SCORE/DATE:________________________

Maryland Board of Professional Counselors and Therapists

LAW SCORE/DATE:_________________________

4201 Patterson Avenue

BCKGRD RESULTS: _______________________

Baltimore, MD 21215 3rd Floor

REVIEWER: ______________________________

410-764-4732

DATE REVIEWED:__________________________

www.dhmh.maryland.gov/bopc

COMMENTS:_______________________________

TYPE OR PRINT ALL INFORMATION

VETERANS AND SPOUSAL PREFERENCE

1)

Are you an active service member or the spouse of an active service member? Yes

No

2)

Are you a veteran or the spouse of a veteran who was discharged from active duty under circumstances other than dishonorable within one (1) year of

filing this application? Yes

No

DEMOGRAPHIC INFORMATION

Social Security No.

Date of Birth:

Place of Birth:

Name:

Dr.

Mr. Ms. Mrs.

Last Name

First Name

MI

Maiden

Home

Address:

Street

City

County

State

Zip Code

If less than 3

years provide

prior address.

Street

City

County

State

Zip Code

Mailing

Address:(If

different than

above)

Street

City

County

State

Zip Code

Business

Name and

Address:

Name

Street

City

County

State

Zip Code

Home Phone:

Work:

Cell:

Email:

Province/Country if not U.S.

GENDER AND ETHNICITY: This information is optional and will be used for statistical purposes by authorized personnel.

Gender:

Male

Female

Ethnicity: Are you of Hispanic or Latino origin? Yes

No

Check all that apply.

American Indian or Alaska Native

Black or African American

White

Asian

Native Hawaiian or other Pacific Islander

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ACADEMIC TRAINING

ALL APPLICANTS MUST COMPLETE THIS SECTION

Graduate college(s) or universities attended to satisfy academic requirements for licensure. Do not list degrees unrelated to Counseling. List most recent first and provide official transcripts.) Attach additional sheets behind this one, if necessary.

1. Name of School:

(City)	(State)
Inclusive dates attended: From (mo./yr.)	To (mo./yr.)
Degree granted:	Date granted (mo./yr.)
Major Field of Study:
2. Name of School:
(City)	(State)
Inclusive dates attended: From (mo./yr.)	To (mo./yr.)
Degree granted:	Date granted (mo./yr.)
Major Field of Study:
3. Name of School:
(City)	(State)
Inclusive dates attended: From (mo./yr.)	To (mo./yr.)
Degree granted:	Date granted (mo./yr.)
Major Field of Study:
4. Name of School:
(City)	(State)
Inclusive dates attended: From (mo./yr.)	To (mo./yr.)
Degree granted:	Date granted (mo./yr.)
Major Field of Study:
5. Name of School:
(City)	(State)
Inclusive dates attended: From (mo./yr.)	To (mo./yr.)
Degree granted:	Date granted (mo./yr.)
Major Field of Study:

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AFFIDAVIT

In making this application to the Maryland Board of Professional Counselors and Therapists for the issuance of a license, I agree to abide by the rules and regulations of the Maryland Board of Professional Counselors and Therapists and to take all examinations necessary to the processing of my application. Upon issuance of a license, I agree to be bound by the Code of Ethics. I further understand that the fee submitted with this application is non- refundable.

I agree to hold the Maryland Board of Professional Counselors and Therapists, its members, officers, agents, and examiners free from any damage or claim for damage or complaint by reason of any action they or any one of them take in connection with this application, the attendant examination, the grades with respect to any examination, and/or failure of the Board to issue me a license. I hereby grant permission to the Board to seek any information or references it deems fit in securing my credentials pertinent to this application.

I understand, by law, it is my responsibility to notify the Board in writing if I change my address of residence.

Signed __________________________________

Date: ___________________________________

NOTARY

State of ____________________________________

City/County of ______________________________

I HEREBY CERTIFY that on this ____________ day of __________________, before me, a Notary Public of the

State and City/County aforesaid, personally appeared ______________________________

__________________________________________, and made oath in due form that the contents of the foregoing

Affidavit are true.

Notary Public __________________________________________

Commission Expires ____________________________________

ATTACH YOUR PHOTOGRAPH IN THIS AREA (RECENT 2”x2”)

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FILL OUT THE COURSE DESCRIPTION FORM AND RETURN IT WITH YOUR APPLICATION

INCLUDE OFFICIAL

TRANSCRIPT(S) TO VERIFY

COURSES

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