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Request for Supervised Practice Form

The Board of Professional Counseling (“the Board”) uses this form to consider whether to allow an applicant the ability to work for 120 days while a completed application with required documents is being processed. For a list of all required documents, please see the application check lists. Applicants cannot begin work without Board approval.
 
An approval will not be granted if the following exists:
  1. No application on file with the Board;
  2. No FBI criminal background result;
  3. Positive criminal background result(s);
  4. Termination from employment is reported; and/or
  5. Prior disciplinary action by a licensure board in any state/jurisdiction is found.
If the supervised practice form is approved, the allowance is only for work with the supervisor approved at the location identified on the form. The allowance is a one-time issuance good for 120 days from the date of approval.