Lgpc Lcpc Form – Fill Out and Use This PDF

Larry Hogan, Governor ∙ Boyd K. Rutherford, Lt. Governor ∙ Robert R. Neall, Secretary

TRANSFER FROM LGPC to LCPC

APPLICATION INSTRUCTIONS

** IMPORTANT **

This form is to be used ONLY if you are a Maryland Licensed Graduate Professional Counselor (LGPC) with an active license, in good standing, and are seeking licensure as a Licensed Clinical Professional Counselor (LCPC).

BEFORE submitting your application, please:

□Retain a copy of all documents for your records. Documents will not be returned once received by the Board.

□All forms must be legible, complete, signed, and dated (where applicable) or processing may be delayed. If information and documentation was provided to the Board with your LGPC application, you do not need to provide it again. However, Maryland law requires that you obtain another criminal history record check (CHRC) even though you obtained one when you applied for LGPC. Forms for the CHRC are included with this application.

□Include a check or money order in the amount of $350 payable to:

Board of Professional Counselors and Therapists. Fees are non-refundable and non-transferable.

□Applications may not be submitted via fax or email. Please mail to:

Board of Professional Counselors and Therapists

Attn: Licensing Coordinator

4201 Patterson Avenue, Suite 316

Baltimore, MD 21215

ELIGIBLITY/REQUIREMENTS: The following is a summary only. For complete requirements and definitions, see Md. Code Ann. Health Occ., §17-101, et. seq. which may be found on the Board’s website,

www.health.maryland.gov/bopc.

□Education: Applicant shall:

Hold a master’s degree (minimum of 60 credits) or a doctoral degree (minimum of 90 credits) in a professional counseling or related field from an accredited educational institution approved by the Board.

Documentation of graduate coursework as set forth in COMAR 10.58.01.05A(2) and B, which includes 3 semester credits in each of the following areas:

▪Human growth and personality development;

▪Social and cultural foundations of counseling;

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▪Counseling theory;

▪Counseling techniques;

▪Group dynamics, processing, and counseling; ▪Lifestyle and career development; ▪Appraisal;

▪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 and emotional disorders.

□Clinical Supervision Requirements:

If you hold a master’s degree, as set forth above, you must have not less than three (3) years and

a minimum of 3000 hours of supervised clinical experience in professional counseling, of which two (2) years and 2,000 hours shall have been completed after the award of the master’s degree obtained under

the supervision of a Board approved supervisor. See COMAR 10.58.01.05B(2).

If you hold a doctoral degree, as set forth above, you must have not less than two (2) years and a minimum of 2000 hour of supervised clinical experience in professional counseling, one year of which shall have been completed after the award of the doctoral degree and obtained under the supervision of a Board approved supervisor. See COMAR 10.58.01.05B(3).

□Examinations. Applicant must pass the following:

1)The National Counselors Exam (NCE); and

2)Maryland Law Assessment.

1)NCE: Upon review of your application, the Board will determine if you are eligible to take the NCE. Once you are deemed eligible, the Board will send you written authorization and

instructions on how to register for the exam. The exam is computerized. Exam dates and locations can be found on the Board’s website. If you have already passed the NCE, please include a copy of your scores with the application.

2)Maryland Law Assessment

The purpose of the assessment is to determine if a candidate is familiar with the state laws and ethical code related to safe and effective practice across several content areas. The MLA is a no-fail, no score assessment. Content areas include supervision and ethics questions based on excerpts from the Code of Maryland Regulations (COMAR) and Md. Code Ann., Health Occupations Art., Title 17.

The MLA consists of 36 questions. You will be presented with readings and questions until all items are answered correctly. Upon successful completion, you will receive a Certificate of Completion that you will submit to the Board with your application for licensure or certification.

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Prior Board approval is not required to take the MLA. However, if you take the MLA before you submit an application for licensure/certification with the Board, please note the following:

-Should you later decide not to apply for licensure/certification with the Board, the MLA fee will not be refunded.

-You are responsible for submitting the MLA Certificate of Completion to the Board with your application for licensure/certification. Do not email, fax or mail the certificate of completion separately to the Maryland Board. MLA Certificates of Completion received without a completed application will not be retained.

-MLA Certificates of Completion are valid for one year from the date of the MLA. If you do not apply for licensure/certification within one year from the date of the MLA, you will be required to re-take the MLA at your additional expense.

To take the MLA, use the following link: www.academy.cce-global.org.

If you experience any issues, please contact the assessment administrator, CCE, Monday thru Friday 8:30am – 5pm at 336.482.2856. You may also email for technical support at support@cce-global.org. Please do not contact the Board regarding technical support issues.

If you have already taken and passed the previous Maryland Law Exam, this notice does not apply to you and no further action is necessary.

□Criminal History Records Check (instructions and form attached). All applicants must complete a criminal history records check (CHRC). Applicant must include a copy of the receipt from the CHRC with this application. This allows the Board to access the report online from the Criminal Justice Information System.

Please note: A license will not be issued unless and until the Board determines that the applicant has completed ALL requirements including required coursework, examinations, CHRC, and any other requirements set by the Board in accordance with Maryland law.

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Larry Hogan, Governor ∙ Boyd K. Rutherford, Lt. Governor ∙ Robert R. Neall, Secretary

TRANSFER FROM LGPC TO LCPC

APPLICATION

Please type or print all information.

I.VETERANS AND SPOUSAL PREFERENCE

Are you an active service member or the spouse of any active service member? □ Yes □ No

Are you a veteran or the spouse of a veteran who was discharged from active

duty under circumstances other than dishonorable within one year of filing this □ Yes □ No application?

II.DEMOGRAPHIC INFORMATION

Name: ________________________________________________________________________

Last	First	MI	Maiden
SSN: ____________________	Date of Birth: ______________ LGPC Lic.# ______________

Home Phone: ____________ Work: ____________ Cell: _____________ Email: ____________

Home Address: _________________________________________________________________

Street CityState Zip

Prior address: __________________________________________________________________

(If less than 3 years at current address) Street CityState Zip

Mailing Address: _______________________________________________________________

(If different than above)Street CityState Zip

Business: _____________________________________________________________________

NameStreet CityState Zip

Gender and Ethnicity: This information is optional and may 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		□ Asian	□ White
	□ Black or African American		□ Native Hawaiian or Pacific Islander

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III. INFORMATION REGARDING BACKGROUND

Please answer Yes or No to each question.

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IV. EDUCATION: List colleges or universities attended to satisfy academic requirementsfor licensure or certification. Do not list degrees unrelated to counseling. Please list the most recent colleges/universities first and provide OFFICIAL transcripts. Attach additional sheets, if necessary.

A.

Name of School			City				State
Dates attended: From (mo./yr.)					To (mo./yr.)
Degree awarded:					Date awarded:
Major field of study:

B.

	Name of School			City				State
	Dates attended: From (mo./yr.)					To (mo./yr.)
	Degree awarded:					Date awarded:
	Major field of study:
C.
	Name of School			City				State
	Dates attended: From (mo./yr.)					To (mo./yr.)
	Degree awarded:					Date awarded:
	Major field of study:

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VI. EXAMINATIONS

A. Have you passed the NCE exam? □ Yes □ No If yes, please include a copy of test score.

B. Have you passed the Maryland Law Assessment? □ Yes □ No Date of exam: __________________

VII. PROFESSIONAL REFERENCES (3): List at least 3 professional references who can attest to your counseling skills, professional standards of practice and supervised clinical work. You must include three (3) Professional Reference assessment forms in their original sealed envelopes with the application. Forms are attached.

A.Name of Reference: _ ___________________________________________________________

Degree: ________________________ Certification/License: __________________________

Position: _________________________ Business Name: ____________________________

Business Address: _____________________________________________________________

Business Phone: _________________________

Will this reference be verifying some or all of your supervised clinical experience? □ Yes □ No

B.

Name of Reference: _ ___________________________________________________________

Degree: ________________________ Certification/License: __________________________

Position: _________________________ Business Name: ____________________________

Business Address: _____________________________________________________________

Business Phone: _________________________

Will this reference be verifying some or all of your supervised clinical experience? □ Yes □ No

C.Name of Reference: _ ___________________________________________________________

Degree: ________________________ Certification/License: __________________________

Position: _________________________ Business Name: ____________________________

Business Address: _____________________________________________________________

Business Phone: _________________________

Will this reference be verifying some or all of your supervised clinical experience? □ Yes □ No

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VIII. SUPERVISED CLINICAL EXPERIENCE: I have:

□attained at least 3 years and 3000 hours of supervised clinical experience, two years of which was

earned after the award of my master’s degree OR

□attained at least 2 years and 2000 hours of supervised clinical experience, one year of which was earned after the award of my doctoral degree; as set forth below:

A.Practicum/Internship (Clinical counseling hours that were obtained as part of masters/doctoral program. Up to 1000 hours may be applied toward the total 3000 hours required for licensure)

1. Agency/school/organization where internship was obtained: ________________________

Name and credential of supervisor: ____________________________________________

Inclusive dates of experience: from (mo./yr.) _______ to (mo.yr.) ________

Total number of months worked: _______ Total number of hours per week: _______

Total number of hours worked during practicum/internship (No. of months x 4 x no. hours worked each week: _______ ; ________ hours direct clinical counseling services and _______

hours of indirect clinical counseling services.

2.Agency/school/organization where internship was obtained: ________________________

Name and credential of supervisor: ____________________________________________

Inclusive dates of experience: from (mo./yr.) _______ to (mo.yr.) ________

Total number of months worked: _______ Total number of hours per week: _______

Total number of hours worked (No. of months x 4 x no. hours worked each week: _______ ;

________ hours direct clinical counseling services and _______ hours of indirect clinical

counseling services.

□As further set forth in the attached Supervised Clinical Experience (Internship) Verification(s).

Summary of Internship/Practicum Hours:

Total number of direct clinical counseling services accrued during Internship/Practicum to be applied toward licensure: __________ hours.

Total number of indirect clinical counseling services accrued during Internship/Practicum to be applied toward licensure: __________ hours.

B.Clinical counseling experience obtained after the award of master’s or doctoral degree:

1. Agency/ /organization name and address: _____________________________________

Name and credential of supervisor: ____________________ Phone:____________________

Inclusive dates of experience: from (mo./yr.) _______ to (mo.yr.) ________

Applicant’s job title and duties: _________________________________________________

Total number of months worked: _______

Total number of hours per week: _______

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□I grant permission to the Board to seek any information or references it deems appropriate or necessary in verifying my credentials as it pertains to this application.

□I understand, by law, it is my responsibility to notify the Board, in writing, of any change of contact information including address, phone number, and/or email address.

I do hereby affirm that all of the statements made herein are true and correct to the best of my knowledge and belief. I voluntarily consent to a thorough review of the information in this application and other activities for the purpose of verifying my qualifications for licensure.

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: _________________.

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Larry Hogan, Governor ∙ Boyd K. Rutherford, Lt. Governor ∙ Robert R. Neall, Secretary

CLINICAL SUPERVISION EXPERIENCE VERIFICATION

(Internship/Practicum Supervised Clinical Counseling Experience)

To Applicant: You must submit this form for each clinical counseling experience that you intend to apply toward the hours required for licensure. Please make additional copies as needed.

I hereby attest that, to the best of my knowledge, information, and belief, that

__________________________ obtained clinical experience under my Applicant’s Name

supervision, as part of his/her internship/practicum, from _____________ to _____________

mo./yr.mo./yr.

at _______________________________________________________________________________________.

Name and Address Agency/Org.

as set forth below:

1.Direct Clinical Counseling Services*: ___________ hours.

2.Indirect Clinical Counseling Services**: ___________ hours.

As the Supervisor of this applicant, do you have any reservations about the applicant receiving a license for the independent practice of counseling?

□ Yes (please use additional sheets to explain)		□ No
________________________	____________________________________
Name (printed)	Lic. Type, Number and State of Issuance
________________________	______________________
Signature	Date

Business Address: __________________________________________________

Phone: ___________________

Email: ________________________

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*” Direct Clinical Counseling Services” means the provision of face to face clinical professional counseling services to clients and their significant others that includes, but is not limited to, the following:

a. Individual counseling; b. Group counseling; c. Family counseling; d. Couples counseling;

e.Evaluation;

f.Intake and assessment;

g.Diagnosis;

h.Treatment planning with client; and

i.Crisis management/intervention.

**“Indirect Clinical Counseling Services” means all case management and professional development activities related to the provision of clinical professional counseling services to a client that include, but are not limited to, the following:

a.Referral;

b.Intake or assessment by telephone or other means when client is not face to face;

c.Receiving individual or group supervision at site;

d.Consultation with other professionals;

e.Treatment planning with other professionals

f.Case staffing;

g.Staff meetings;

h.Related trainings and seminars;

i.Record keeping;

j.Report writing;

k.Case notes;

l.Telephone triage; and

m.Other clinical counseling administrative duties as required by the setting in which the clinical hours are accrued.

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Larry Hogan, Governor ∙ Boyd K. Rutherford, Lt. Governor ∙ Robert R. Neall, Secretary

CLINICAL SUPERVISION EXPERIENCE VERIFICATION

(Post-Graduate Supervised Clinical Counseling Experience)

To Applicant: You must submit this form for each clinical counseling experience that you intend to apply toward the hours required for licensure. Please make additional copies as needed.

I hereby attest that, to the best of my knowledge, information, and belief, that

__________________________ obtained post-graduate clinical counseling experience

Applicant’s Name

under my supervision, as a Board-approved Supervisor, from ___________ to ___________

(mo./yr.) (mo./yr.)

at _______________________________________________________________________________________,

Name and Address Agency/Org.

as set forth below:

3.Direct Clinical Counseling Services*: ___________ hours.

4.Indirect Clinical Counseling Services**: ___________ hours.

5.Face to face*** Supervision between Board Approved Supervisor and Supervisee:

a.Individual face to face supervision: ___________ hours.

b.Group face to face supervision: ___________hours.

As the Board-approved supervisor of this applicant, do you have any reservations about the applicant receiving a license for the independent practice of counseling?

□ Yes (please use additional sheets to explain)		□ No
________________________	____________________________________
Name (printed)	Lic. Type, Number and State of Issuance
________________________	______________________
Signature	Date

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Business Address: __________________________________________________

Phone: ___________________

Email: ________________________

*” Direct Clinical Counseling Services” means the provision of face to face clinical professional counseling services to clients and their significant others that includes, but is not limited to, the following:

a. Individual counseling; b. Group counseling; c. Family counseling; d. Couples counseling;

e.Evaluation;

f.Intake and assessment;

g.Diagnosis;

h.Treatment planning with client; and

i.Crisis management/intervention.

**“Indirect Clinical Counseling Services” means all case management and professional development activities related to the provision of clinical professional counseling services to a client that include, but are not limited to, the following:

a.Referral;

b.Intake or assessment by telephone or other means when client is not face to face;

c.Receiving individual or group supervision at site;

d.Consultation with other professionals;

e.Treatment planning with other professionals

f.Case staffing;

g.Staff meetings;

h.Related trainings and seminars;

i.Record keeping;

j.Report writing;

k.Case notes;

l.Telephone triage; and

m.Other clinical counseling administrative duties as required by the setting in which the clinical hours were accrued.

***“Face-to-face” means in the physical presence of the individuals involved in the supervisory relationship during either individual or group supervision or using video conferencing which allows individuals to hear and see each other in actual points of time. It does not include telephone supervision; or internet communication that does not involve actual or real-time video conferencing such as instant messaging services and social networking sites. COMAR 10.58.12.02

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PROFESSIONAL REFERENCE ASSESSMENT

Applicant’s Name: ________________________

The above-named individual has applied to the Maryland State Board of Professional Counselors and

Therapists to become a licensed professional counselor. Your assessment will help determine the applicant’s eligibility for licensure. Please answer all questions to the best of your knowledge,

information, and belief.

PLEASE RETURN THE COMPLETED FORM TO THE APPLICANT IN A SEALED ENVELOPE.

Reference’s Name: ______________________________ Phone: ______________________

Business Address: _________________________________________________________________

Degree: ____________________

Title: ____________________

Professional Certification/License: ______________________ State/Certifying Org.: _______________

Relationship to Applicant: □ Educator □ Prof. Colleague					□ Supervisor (must sign Supervision
Verification form)	□ Other: ____________________
Length of time you have known Applicant: From (mo./yr.) ________ To (mo./yr.) __________
Please rate the Applicant on the			Outstanding	Above Avg.	Average	Below	Poor	Cannot
following skills/characteristics.						Avg.		evaluate
Place a check √ in each category.
(Applicants who are counselor
educators should be evaluated on the
basis of their ability to train students in
counseling skill areas).
Individual counseling skills
Appropriate referral making skills
Group counseling skills
Personal integrity
Consulting skills
Insight to client’s problems
Ability to relate to co-workers
Objectivity on the job
Ethical conduct
Concern for welfare of clients
Sense of responsibility
Recognition of own limits
Supervisory ability
Ability to keep material confidential
Additional Comments (optional):		________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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I recommend this Applicant for licensure as a clinical professional counselor: □ Yes

□ No

The information provided above is based on my best knowledge, information, and belief. I agree to answer additional questions regarding this evaluation if requested by the Board.

______________________________	_________________________
Reference’s signature	Date

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PROFESSIONAL REFERENCE ASSESSMENT

Applicant’s Name: ________________________

The above-named individual has applied to the Maryland State Board of Professional Counselors and

Therapists to become a licensed professional counselor. Your assessment will help determine the applicant’s eligibility for licensure. Please answer all questions to the best of your knowledge,

information, and belief.

PLEASE RETURN THE COMPLETED FORM TO THE APPLICANT IN A SEALED ENVELOPE.

Reference’s Name: ______________________________ Phone: ______________________

Business Address: _________________________________________________________________

Degree: ____________________

Title: ____________________

Professional Certification/License: ______________________ State/Certifying Org.: _______________

Relationship to Applicant: □ Educator □ Prof. Colleague					□ Supervisor (must sign Supervision
Verification form)	□ Other: ____________________
Length of time you have known Applicant: From (mo./yr.) ________ To (mo./yr.) __________
Please rate the Applicant on the			Outstanding	Above Avg.	Average	Below	Poor	Cannot
following skills/characteristics.						Avg.		evaluate
Place a check √ in each category.
(Applicants who are counselor
educators should be evaluated on the
basis of their ability to train students in
counseling skill areas).
Individual counseling skills
Appropriate referral making skills
Group counseling skills
Personal integrity
Consulting skills
Insight to client’s problems
Ability to relate to co-workers
Objectivity on the job
Ethical conduct
Concern for welfare of clients
Sense of responsibility
Recognition of own limits
Supervisory ability
Ability to keep material confidential
Additional Comments (optional):		________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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I recommend this Applicant for licensure as a clinical professional counselor: □ Yes

□ No

The information provided above is based on my best knowledge, information, and belief. I agree to answer additional questions regarding this evaluation if requested by the Board.

______________________________	_________________________
Reference’s signature	Date

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PROFESSIONAL REFERENCE ASSESSMENT

Applicant’s Name: ________________________

The above-named individual has applied to the Maryland State Board of Professional Counselors and

Therapists to become a licensed professional counselor. Your assessment will help determine the applicant’s eligibility for licensure. Please answer all questions to the best of your knowledge,

information, and belief.

PLEASE RETURN THE COMPLETED FORM TO THE APPLICANT IN A SEALED ENVELOPE.

Reference’s Name: ______________________________ Phone: ______________________

Business Address: _________________________________________________________________

Degree: ____________________

Title: ____________________

Professional Certification/License: ______________________ State/Certifying Org.: _______________

Relationship to Applicant: □ Educator □ Prof. Colleague					□ Supervisor (must sign Supervision
Verification form)	□ Other: ____________________
Length of time you have known Applicant: From (mo./yr.) ________ To (mo./yr.) __________
Please rate the Applicant on the			Outstanding	Above Avg.	Average	Below	Poor	Cannot
following skills/characteristics.						Avg.		evaluate
Place a check √ in each category.
(Applicants who are counselor
educators should be evaluated on the
basis of their ability to train students in
counseling skill areas).
Individual counseling skills
Appropriate referral making skills
Group counseling skills
Personal integrity
Consulting skills
Insight to client’s problems
Ability to relate to co-workers
Objectivity on the job
Ethical conduct
Concern for welfare of clients
Sense of responsibility
Recognition of own limits
Supervisory ability
Ability to keep material confidential
Additional Comments (optional):		________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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I recommend this Applicant for licensure as a clinical professional counselor: □ Yes

□ No

The information provided above is based on my best knowledge, information, and belief. I agree to answer additional questions regarding this evaluation if requested by the Board.

______________________________	_________________________
Reference’s signature	Date

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Larry Hogan, Governor ∙ Boyd K. Rutherford, Lt. Governor ∙ Robert R. Neall, Secretary

NOTICE OF CRIMINAL HISTORY RECORDS

CHECK

Effective January 1, 2014, the Maryland Board of Professional Counselors and Therapists (the "Board”) requires that all applicants for licensure, certification, and trainee status complete a

criminal history records check in accordance with §§17-501 and 17-501.1 of the Health Occupations Article, Annotated Code of Maryland.

A Criminal History Records Check includes a national and state criminal history background search. The criminal history records check requires you tobefingerprinted. In order to be fingerprinted, you will need to complete and present the Live Scan Pre-Registration Form. (Attached).

You must present this form to thefingerprintingsitebecause it providestheCriminalJustice Information System (CJIS) authorization number #1300005490and theFBI ORI number #MD920512Zassigned specificallyto the Board.

This allows the information to be forwarded directly to the Board.

For additional information contact CJIS at 410-764-4501. For current listings of fingerprinting providers please go to http: //www.dpscs.maryland.gov/publicservs/fingerprint.shtml.

FOR FAST AND ACCURATE SERVICE

1.When requesting a criminalhistory records check for licensing purposes you must have an agency name and authorization number (Listed above).

2.Your background check isbeing sent to the Board.

3.You must bring a valid form of government identification. (Examples: driver's license, Certificate of Naturalization, passport, AlienRegistration Card, or Military Identification).

4.Complete the Live Scan Pre-registration Application and bring it to any fingerprinting center/provider.

5.Bring payment as indicated above. The Board will receive the results from the criminal history records check directly from CJIS within 5-7 business days. The Board will contact you if it has any questions regarding the report. Please do not contact the Board to check if the report has been received.

6.Please do not send the Live Scan Pre-registration Application to the Board. You must present it at the fingerprint center/provider location.

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