Documentation of Experience for Counselor …

1 Documentation of Experience for Counselor Interns (For Licensure as a licensed professional Counselor ) General Instructions: The purpose of the Documentation of Experience Form (DOE) is for Counselor Interns and their Supervisors to submit information documenting the Counselor Intern s supervised Experience and readiness for licensure. Per the requirements listed in Chapters 5 and 7 of the LPC Board Rules, those wishing to pursue licensure must complete the following items as part of meeting the requirements for licensure as a LPC: o A minimum of 2 years and a maximum of 7 years supervised work Experience with an LPC Board-approved supervisor (LPC-S). o Supervised Work Experience must include: 3000 hours of clinical services in professional mental health counseling Of these 3000 hours, a minimum of 1900 must be direct client contact hours, 1000 must be indirect contact hours, and 100 hours must be face-to-face supervision by a LPC-S. Applicants are to complete Section 1 of this form and present the form to their supervisor to complete Section 2.

2 Please note that applicants must sign the form in Section 2 following the supervisor s evaluation in addition to the signature in Section 1. Supervisors are to review Section 1 of this form and complete Section 2. Supervisors are to return the form directly to the Board office at the following address: licensed professional Counselors Board of Examiners 8631 Summa Avenue Baton Rouge, LA 70809 Additional information may be obtained by contacting the Board by: Phone: (225) 765-2515 Fax: (225) 765-2514 Email: Website: Please note that when making inquiries to the Board, staff members are unable to pre-approve any applications. Please consult the Board s website to obtain any applicable laws/rules in answering your inquiries. Official inquiries to the Board may be made in writing via email or regular mail. 1 Documentation of Experience for Counselor Interns (For Licensure as a licensed professional Counselor ) Section I (To Be Completed By Applicant): Dear _____ (Name of Supervisor) I am applying for licensure as a licensed professional Counselor to be issued by the Louisiana licensed professional Counselors Board of Examiners.

3 To validate the Experience required of me to obtain a license, the members of the Board would appreciate your providing them with information regarding my counseling Experience . I hereby consent to the release of any information, favorable or otherwise, which you may have concerning my employment or my practice. Please return the completed from directly to the Board at 8631 Summa Ave., Baton Rouge, LA 70809. Applicant s Signature: _____ Date: _____ Applicant s Full Name: _____ Mailing Address: _____ _____ Home Phone: _____ Business Phone: _____ Email: _____ Name of setting(s) _____ where internship took place: _____ _____ 2 Hours of Supervision: To obtain the total number of supervised Experience hours, add direct client contact hours, indirect hours and the face-to-face hours of supervised Experience . Dates of Supervision: From _____ to _____ (Mo/Yr) (Mo/Yr) Direct Client Contact Hours: + _____ Indirect Client Contact Hours: + _____ Face-to-Face Hours with Supervisor: + _____ TOTAL Number of Supervised Experience Hours: = _____ Section II (To Be Completed By Applicant s Supervisor): Supervisor s Full Name: _____ Mailing Address: _____ _____ Home Phone: _____ Business Phone: _____ Email: _____ Areas of Evaluation (To Be Completed By Supervisor): Please provide your evaluation of the supervisee by choosing the answer that best approximates the applications level of skill in the following.

4 1-Unsatisfactory 2-Below Average 3-Average 4-Above Average 5-Superior 1. Exhibits knowledge counseling theories: 1 2 3 4 5 2. Ability to conceptualize cases: 1 2 3 4 5 3. Knowledge and use of appropriate techniques: 1 2 3 4 5 4. Ability to develop therapeutic alliance with clients: 1 2 3 4 5 5. Exhibits appropriate communication skills: 1 2 3 4 5 6. Exhibits appropriate assessment skills: 1 2 3 4 5 3 7. Exhibits intervention skills: 1 2 3 4 5 8. Exhibits qualities of the professional self: 1 2 3 4 5 9. Demonstrates knowledge and practice of LPC rules and ethics: 1 2 3 4 5 Briefly describe your Experience in working with the supervisee applying for licensure, elaborating on the ratings indicated above. _____ _____ _____ Do you know of any lawsuit or court action pending against the applicant concerning her/his professional duties? YES NO If yes, please explain: _____ _____ _____ As the supervisor of the applicant s counseling Experience , do you recommend this person for licensure?

5 YES NO If no, please explain in detail on a separate sheet. The Board encourages all supervisors to review the information contained in this evaluation with the applicant prior to submitting it to the Board. I have reviewed the applicant s Documentation of Experience in Section 1 of this form. The reported hours in each category are/ are not substantially correct. Supervisor s Signature: _____ Date: _____ Applicant s Signature: _____ Date: _____