Nc Blpc Form PDF Details

Embarking on the journey to licensure as a Licensed Professional Counselor Associate (LPCA) in North Carolina is a critical step for new graduates aiming to enter the field of professional counseling. This pivotal process is governed by a comprehensive application outlined by the North Carolina Board of Licensed Professional Counselors (NCBLPC), which requires meticulous attention to detail across several areas. Applicants are obligated to complete an extensive form, ensuring they provide their personal details, educational background, and a thorough accounting of their training and experience. This includes a requirement for graduate transcripts, professional references, and documentation of practicum and internship experiences to be sent directly to the NCBLPC. Additionally, applicants must engage with critical self-disclosure regarding their legal and ethics history, attaching explanations for any affirmative answers which highlight the board's emphasis on professional integrity. With a mandatory criminal background check facilitated through the submission of fingerprint cards, and a comprehensive checklist including the submission of a professional disclosure statement and jurisprudence exam certification, the application process is designed to affirm the candidate's readiness and suitability for the counseling profession. The non-refundable application fee, which includes the cost for the criminal background check, signifies the financial commitment applicants must make towards securing their LPCA designation. The intricacies of the application instructions underscore the importance of accuracy and thoroughness, reflecting the board's commitment to upholding high standards within the counseling profession.

QuestionAnswer
Form NameNc Blpc Form
Form Length10 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 30 sec
Other namesLPC Associate Application LPC Associate Application.pdf - NCBLPC: NC Board of Licensed ... - ncblpc

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North Carolina Board of Licensed Professional Counselors

LPC Associate Licensure Application

Pre-requisite for LPC license for new graduates

Checklist for LPCA Applicants

I have read the Application Process for LPCAs.

I have completed all of Section I. Social Security Number and Date of Birth are required.

I have listed all licenses and certificates that I hold issued in North Carolina and other states in Section II.

I have enclosed a written explanation for questions answered with a “Yes” in

Section III — Legal and Ethics History.

I have listed all graduate institutions attended in Section IV and have requested transcripts to be sent directly to the NCBLPC.

I have listed three (3) professional references with contact information and the length of time I have known them in Section V.

I have listed my graduate counseling experience (practicum and internship) in Section VI and I have requested that a faculty member in my university counseling department complete the Verification of Graduate Counseling Experience form to be sent directly to the NCBLPC.

I have listed my graduate course work with course codes and semester or quarter hours in Section VII.

I have attached a photo (no larger than 2“ x 2”), signed and dated the application and have had my application notarized in Section VIII.

I have signed and dated the application in the presence of a Notary Public and have had my application notarized in Section IX.

I have enclosed two fingerprint cards and the Authority for Release of Information (see page 11) to be submitted by the NCBLPC for state and national background checks to be performed by the SBI and FBI as required in Section XII.

I have included my application fee of $238, includes fee for criminal background check

I have included my LPCA Professional Disclosure Statement.

I have included my LPCA Jurisprudence Exam Certificate of Completion.

This version supersedes all previous versions

Application Page 1 of 10

Revised 03/25/14

North Carolina Board of Licensed Professional Counselors

Licensure Application

Licensed Professional Counselor Associate

Pre-requisite for LPC license for new graduates

APPLICATION INSTRUCTIONS

1.PRINT or TYPE using BLACK Ink to complete this application.

2.Applicants must complete ALL SECTIONS. Read carefully.

3.A completed application and other required support documentation are to be mailed in one packet to the Board’s address.

4.The application fee is $200 plus an additional $38 for the criminal background check and must accompany the application when mailed. Application fees are non-refundable.

I. GENERAL INFORMATION - To be completed by all applicants.

 

Name (Last, First, Middle):

Social Security Number:

Date of Birth:

___________________________________________

______________________

______________________

 

(required)

(mm/dd/yyyy)

Please include maiden name and/or any other alias:

 

 

________________________________________________

 

Mailing Address (Street and/or Box Number, City, State, Zip Code):

Home Phone:

__________________________________________________________

_________________________

Email Address:

 

Mobile Phone:

___________________________________________________________

_________________________

Business Name & Address (is this an exempt setting, such as a school, university or government agency)?: Yes No

_________________________________________________

Work Phone:

_________________________________________________

_________________________

_________________________________________________

 

Email Address:

Work Fax:

_________________________________________________

_________________________

II.CREDENTIALS - To be completed by all applicants, if applicable.

List all professional credentials which you now hold or have ever held in order of attainment.

License/Certificate Type

License/Certificate # Issued Date

Issued By

Amount $

Payment: CC Check MO

For Office Use Only Date Rec’d:

This version supersedes all previous versions

Application Page 2 of 10

Revised 03/25/14

Name of Applicant: (Required)

III.LEGAL & ETHICS HISTORY - To be completed by all applicants. All applicants are REQUIRED to submit two

(2) fingerprint cards, the Authorization for Release of Information and payment of $38 to the NCBLPC for a state and national background check to be performed.

1.Have you ever been denied the privilege of taking an occupational licensure or certification examination? If yes, state what type of occupational examination, where, and provide final written decision from the denying Board on a separate sheet of paper.

2.Have you ever had any disciplinary action taken against an occupational license or certificate to practice or are any such actions pending? If yes, explain in detail on a separate sheet of paper.

3.Have you ever been convicted of a violation of/or pled nolo contend ere to any federal, state, or local statute, regulation or ordinance or entered into any plea bargain for violations, except for minor traffic violations? If yes, see below.**

4.Within the past four years, have you been unable to engage in the practice of counseling due to a physical and/or emotional dependency or use of alcohol and/or drugs? If yes, please provide a letter from your treating professional summarizing diagnosis, treatment and prognosis.

5.Within the past four years, have you been unable to engage in the practice of counseling due to treatment and/or hospitalization for a nervous, emotional or mental disorder? If yes, please provide a letter from your treating professional summarizing diagnosis, treatment and prognosis.

6.Have you ever been censured, warned, or requested to withdraw from your practice/employment, terminated from any health care facility, agency, or practice for reasons involving your conduct as a counselor? If yes, please provide an explanation on a separate sheet of paper.

7.Have you ever been convicted of an offense involving the taking of illegal drugs or the consumption of alcohol? If yes, see below.**

If you answered YES to questions 3 and/or 7, you must submit:

1)A written explanation of the event(s).

2)A written explanation on how you have dealt with the circumstances that lead up to the event(s).

1.

Yes No

2.

Yes No

3.

Yes No

4.

Yes No

5.

Yes No

6.

Yes No

7.

Yes No

IV. EDUCATION - To be completed by all applicants. Official Graduate Transcripts from each of the Universities listed below must be submitted directly to the NCBLPC Board Office from the Graduate Institution.

Graduate Institution

(Undergraduate Not Required)

Dates of Attendance

From To

Major/Degree Received

Date Degree

 

Conferred

V. REFERENCES - To be completed by all applicants. Please list three individuals (may include supervisors) who are acquainted with your professional counseling work.

Name, Address, & Phone

Title

Yrs Known

This version supersedes all previous versions

Application Page 3 of 10

Revised 03/25/14

Name of Applicant: (Required)

VI. Graduate Counseling Experience - To be completed by all applicants. List below your graduate Practicum and Internship experiences (use additional sheets if necessary). These experiences should appear on your graduate transcript(s). Send Verification of Graduate Counseling Experience form(s) to your University. A faculty member/university supervisor should complete the form and send it directly to the NCBLPC. Practicum and Internship are defined in Rule .0701(B).

1. Dates of

Practicum

Total # of weeks:

 

 

 

# of hours per week:

 

 

 

From:

 

 

To:

Course # and Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Graduate Institution:

 

 

 

University Supervisor:

 

 

 

Practicum/Internship Site:

 

 

 

Site Supervisor:

 

 

 

Position Held/Responsibilities:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Dates of

Practicum

Total # of weeks:

 

 

 

# of hours per week:

 

 

 

From:

 

 

To:

Course # and Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Graduate Institution:

 

 

 

University Supervisor:

 

 

 

Practicum/Internship Site:

 

 

 

Site Supervisor:

 

 

 

Position Held/Responsibilities:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Dates of

Internship

Total # of weeks:

 

 

 

# of hours per week:

 

 

 

From:

 

 

To:

Course # and Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Graduate Institution:

 

 

 

University Supervisor:

 

 

 

Practicum/Internship Site:

 

 

 

Site Supervisor:

 

 

 

Position Held/Responsibilities:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Dates of

Internship

Total # of weeks:

 

 

 

# of hours per week:

 

 

From:

 

 

To:

Course # and Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Graduate Institution:

 

 

 

University Supervisor:

 

 

Practicum/Internship Site:

 

 

 

Site Supervisor:

 

 

Position Held/Responsibilities:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This version supersedes all previous versions

Application Page 4 of 10

Revised 03/25/14

Name of Applicant: (Required)

VII GRADUATE COURSES - To be completed by all applicants. Course areas are fully defined in Rule .0701 of the Administrative Code and are posted on the Board website. In cases where the course title does not clearly reflect course content, applicants shall provide university course descriptions and/or syllabi for clarification. Each course area must have at least one 3-semester hour (or 5 quarter hour) course unless otherwise specified.

A.HELPING RELATIONSHIPS IN COUNSELING - shall provide a general knowledge of theories, their principles, and techniques for application in counseling relationships; shall include crisis intervention and suicide prevention models.

Course Code

Date Completed

Title

Sem/Qtr hrs

B.PROFESSIONAL ORIENTATION TO COUNSELING - shall provide an understanding of all aspects of functioning as a professional counselor, including a history of the counseling profession, various roles contemporary counselors have in our society, membership in professional counseling associations, self-care strategies appropriate to the counselor role, ethical conduct, standards of preparation, credentialing processes, and counseling supervision models, practices, and processes.

Course Code

Date Completed

Title

Sem/Qtr Hrs

C-1. PRACTICUM IN COUNSELING - Applicant’s must have both a Practicum and an Internship as defined in Rule .0206. Coursework shall be provided in a university-approved counseling setting for at minimum one (1) semester duration (three semester hours or 5 quarter hours of credit) for Practicum and one (1) semester duration for Internship of academic credit in a regionally accredited program of study.

Course Code

Date Completed

Title

Sem/Qtr Hrs

C-2. INTERNSHIP IN COUNSELING - Applicant’s must have both a Practicum and an Internship as defined in Rule .0206. Coursework shall be provided in a university-approved counseling setting for at minimum one (1) semester duration (three semester hours or 5 quarter hours of credit)for Practicum and one (1) semester duration for Internship of academic credit in a regionally accredited program of study.

Course Code

Date Completed

Title

Sem/Qtr Hrs

This version supersedes all previous versions

Application Page 5 of 10

Revised 03/25/14

Name of Applicant: (Required)

VII. GRADUATE COURSES (continued) - To be completed by all applicants. Course areas are fully defined in

Rule .0701 of the Administrative Code and are posted on the Board website. In cases where the course title does not clearly reflect course content, applicants shall provide university course descriptions and/or syllabi for clarification. Each course area must have at least one 3-semester hour (or 5 quarter hour) course unless otherwise specified.

D.ASSESSMENT IN COUNSELING - shall include studies that provide a broad understanding of historical perspectives concerning the nature and meaning of assessment as well as basic concepts of standardized and non-standardized testing and other assessment techniques.

Course Code

Date Completed

Title

Sem/Qtr Hrs

E.CAREER COUNSELING AND LIFESTYLE DEVELOPMENT - shall include studies that provide a broad understanding of career development theories and decision-making models as well as career and educational planning, placement, follow- up, and evaluation.

Course Code

Date Completed

Title

Sem/Qtr Hrs

F.GROUP COUNSELING THEORIES AND PROCESSES - shall include studies that provide a broad understanding of group development, dynamics, methods, and counseling theories; shall help students understand group leadership styles, basic and advanced group skills, and other aspects of group counseling and group consultation.

Course Code

Date Completed

Title

Sem/Qtr Hrs

G.HUMAN GROWTH AND DEVELOPMENT THEORIES IN COUNSELING - shall provide a broad understanding of human behavior, including an understanding of developmental crises, disability, psychopathology, and situational and environmental factors that affect both normal and abnormal behavior.

Course Code

Date Completed

Title

Sem/Qtr Hrs

This version supersedes all previous versions

Application Page 6 of 10

Revised 03/25/14

Name of Applicant: (Required)

VII. GRADUATE COURSES (continued) - To be completed by all applicants. Course areas are fully defined in

Rule .0701 of the Administrative Code and are posted on the Board website. In cases where the course title does not clearly reflect course content, applicants shall provide university course descriptions and/or syllabi for clarification. Each course area must have at least one 3-semester hour (or 5 quarter hour) course unless otherwise specified.

H.RESEARCH AND PROGRAM EVALUATION - shall include studies that provide a broad understanding of the importance of research in advancing the counseling profession; study of research methodology, statistical methods, the use of research to inform evidence-based practice; and ethical and culturally relevant strategies for interpreting and reporting the results of research and/or program evaluation studies.

Course Code

Date Completed

Title

Sem/Qtr Hrs

I.SOCIAL AND CULTURAL FOUNDATIONS IN COUNSELING - shall provide an understanding of theories of multicultural counseling, identity development, and social justice while examining multicultural and pluralistic trends, including characteristics and concerns within and among diverse groups nationally and internationally.

Course Code

Date Completed

Title

Sem/Qtr Hrs

This version supersedes all previous versions

Application Page 7 of 10

Revised 03/25/14

Name of Applicant: (Required)

VIII. PHOTO

Please attach a passport size photo

with tape on each side

Photo should be no larger than 2” x 2”

IX. APPLICATION VALIDATON - To be completed by all applicants. The following statement must be signed in the presence of a Notary Public. This application is not valid unless properly signed and notarized. Note: Any false or misleading information in, or in connection with, any application may be cause for denial of application.

The undersigned, being sworn (or affirmed), deposes and says that he/she is the person who executed this application; that the statements herein contained are true in every aspect; that he/she will conform to the ethical standards and standards of practice in his/her professional conduct; that he/she has read and understands this affidavit.

The undersigned also understands that the Board has the authority to conduct a full criminal record search, including state and national records.

Applicant’s Full Name (PRINTED):

Applicant’s Signature:

Notary Information:

State of

 

 

 

 

 

 

 

City/County of

 

 

 

 

 

 

Sworn to (or affirmed) and subscribed before me,

 

 

 

on this, the

 

day of

, 20

 

SEAL

 

 

 

 

 

 

 

 

Notary Public:

My Commission Expires:

The NCBLPC is charged with the responsibility of reviewing and acting on the applications of qualified persons who are adequately prepared in professional counseling. The Board has no jurisdiction over professions or professionals prepared in other fields that are licensed/certified by other Boards such as Marriage & Family Therapy, Psychology, Fee-Based Pastoral Counseling, Substance Abuse and Social Work.

Mail completed application to: NCBLPC ♦ PO Box 1369 ♦ Garner, NC 27529

This version supersedes all previous versions

Application Page 8 of 10

Revised 03/25/14

X. Criminal Background Information

Instructions for Completing the Applicant Fingerprint Card

Please go to your local law enforcement agency (police department or sheriff’s office) and request that they make two fingerprint cards. The bearer of this letter is seeking to obtain a copy of his or her criminal history record information for pursuant to NCGS 90-345(b) in order to obtain a license from the North Carolina Board of Licensed Professional Counselors.

1.The complete name of the subject is to be listed as indicated: last name, first name, and middle name. Please ensure the name is legible if written.

2.List any and all alias names or nicknames, maiden name, or any other married names.

3.Sex is to be listed as M for Male and F for Female or U for Unknown.

4.Race is to be listed by placing an individual into one (1) of the following categories by writing the appropriate letter in

the space provided. W – White

B – Black

I – American Indian or Alaskan Native A – Asian or Pacific Islander

U – Unknown if unsure or unable to determine

5.Indicate the subject’s height in feet and inches using all numeric.

Example: 6’01’ = 601, 6’11” = 611, 6’ = 600

6.Indicate the subject’s weight in pounds using all numeric.

Example: 186 or 098, etc.

7.List the subject’s eye color by placing one (1) of the following eye color codes in the space provided:

BLK—Black GRY—Gray MAR—Maroon BLU—Blue GRN—Green PNK—Pink BRO—Brown HAZ—Hazel XXX—Unknown

8.Color of hair should be indicated by writing one (1) of the following color codes in the space provided: BAL – Bald (when subject has lost most of his hair or is hairless)

BLK – Black

BLN – Blond or Strawberry BRO – Brown

GRY – Gray or partially RED – Red or Auburn SDY – Sandy

9.List the date of birth numerically– month, day and year

Example: May 11, 1948 should be shown as 05111948

10.Indicate, if possible, the city and state where the subject was born. The state should be indicated by the two letter abbreviation.

11.OCA block: NCBLPC000

12.Social Security: write in the Social Security Number

13.Residence of Person Fingerprinted: Current residence of subject fingerprinted is written here.

14.Employer Board Address: NC Board of Licensed Professional Counselors, PO Box 1369, Garner NC 27529

15.Reason Fingerprinted: Licensed Professional Counselor per NCGS 90-345, state and federal.

This version supersedes all previous versions

Application Page 9 of 10

Revised 03/25/14

XI. Authority for Release for Criminal Background Check

AUTHORITY FOR RELEASE OF INFORMATION

State and Federal Record Check

I authorize the North Carolina Department of Justice through the State Bureau of Investigation, Special

Operations Division, to perform a fingerprint search of the State’s criminal history record file and a fingerprint search of the Federal Bureau of Investigation’s files for a national criminial history record check in connection

with my application for licensure with the North Carolina Board of Licensed Professional Counselors pursuant to NCGS 90-345.

Please type or print clearly; use only black or blue ink.

________________________

_________________________

___________________________

Last Name

First Name

Middle Name

________________________

 

 

 

Maiden Name

 

 

 

________________________

_________________________

_________

_______________

Social Security Number

Date of Birth

Gender

Race

(Optional*)

 

 

 

I understand that the North Carolina State Bureau of Investigation, Special Operations Division, and its officials and employees shall not be held legally accountable in any way for providing this information to the North Carolina Board of Licensed Professional Counselors, and I hereby release said agency and persons from any and all liability which may be incurred as a result of furnishing such information. I further understand that the North Carolina Board of Licensed Professional Counselors cannot provide the results of this criminal history record check to me.

*Disclosure of a social security number is entirely voluntary and not required. If disclosed, the social security number will be utilized to assist with accurate identification/exlusion of possible criminal history checks.

________________________________________________

____________________________

Signature of Applicant

Date

The Authority for Release of Information, the fingerprint card(s) and the fee must be mailed to:

NCBLPC

PO BOX 1369

Garner NC 27529

ORI # NCBC10000 – North Carolina Board of Licensed Professional Counselors

This request form must be maintained on file with the above named agency for one year.

Do not mail this form or a copy of this form

to the State Bureau of Investigation.

This version supersedes all previous versions

Application Page 10 of 10

Revised 03/25/14

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Step 1: The first task is to click the orange "Get Form Now" button.

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The PDF form you are about to prepare will include the following parts:

Nc Blpc Form empty fields to complete

Fill in the I have attached a photo no larger, I have signed and dated the, I have enclosed two fingerprint, I have included my application fee, I have included my LPCA, I have included my LPCA, This version supersedes all, Application Page of, and Revised space using the details required by the software.

Finishing Nc Blpc Form part 2

The system will demand for extra info with the intention to quickly fill in the segment Name Last First Middle, Social Security Number, Date of Birth, required, mmddyyyy, Please include maiden name andor, Mailing Address Street andor Box, Home Phone, Email Address, Mobile Phone, Business Name Address is this an, Work Phone, Email Address, Work Fax, and II CREDENTIALS To be completed by.

stage 3 to finishing Nc Blpc Form

The LicenseCertificate Type, LicenseCertificate Issued Date, Issued By, d c e R e, a D, y n O e s U e c i f f, O r o F, This version supersedes all, Application Page of, and Revised field is where both parties can indicate their rights and responsibilities.

Nc Blpc Form LicenseCertificate Type, LicenseCertificate Issued Date, Issued By, d c e R e, a D, y n O e s U e c i f f, O r o F, This version supersedes all, Application Page of, and Revised fields to fill out

End by taking a look at the following sections and filling them out as required: Name of Applicant Required, III LEGAL ETHICS HISTORY To be, Have you ever been denied the, yes state what type of, Have you ever had any, are any such actions pending If, Have you ever been convicted of a, Within the past four years have, Within the past four years have, Yes No, Yes No, Yes No, Yes No, and Yes No.

Name of Applicant Required, III LEGAL ETHICS HISTORY To be, Have you ever been denied the, yes state what type of, Have you ever had any, are any such actions pending If, Have you ever been convicted of a, Within the past four years have, Within the past four years have, Yes No, Yes No, Yes No, Yes No, and Yes No in Nc Blpc Form

Step 3: When you choose the Done button, your ready document can be simply transferred to any of your gadgets or to electronic mail chosen by you.

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