Fillable APPLICATION FOR BOARD APPROVED LPC, LMFT AND LSATP (Virginia Department of Motor Vehicles)

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APPLICATION FOR BOARD APPROVED LPC, LMFT AND LSATP (Virginia Department of Motor Vehicles)

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Revised 2/2020
9960 Mayland Drive, Suite 300
Henrico, VA 23233-1463
www.dhp.virginia.gov/counseling
Email: coun@dhp.virginia.gov
(804) 367-4610 (Tel)
(804) 767-6225 (Fax)
APPLICATION FOR BOARD APPROVED LPC, LMFT AND LSATP SUPERVISOR
A fee is not required for this approval process. The application must be completed in full and submitted with the required documentation.
If a section does not apply, write “N/A”. Please print or type.
To remain on the registry, you must maintain an active, unrestricted license with the Board. The Board of Counseling may request
updated information periodically, in order to maintain an active public registry. Please note that your public address will be posted on
the registry for public use.
This application allows the Board to review and approve your credentials to provide supervision. Supervision may not begin
until you have an established supervisory contract signed by you and the resident. (Residents applying for initial supervision
approval must be Board approved prior to counting hours toward licensure. Add/change of worksite and/or supervisor does
not need to be pre-approved by the Board but the resident must have an executed supervisory contract between the
supervisor and resident in place before counting hours toward licensure.) Supervision that is not concurrent with a residency
will not be accepted, nor will residency hours be accrued in the absence of Board-approved supervision
PLEASE TYPE OR PRINT CLEARLY
Name of Supervisor (Last, First, Middle)
License Type(s):
License Number(s):
Email Address:
Contact Phone Number:
Supervisor Requirements to supervise RESIDENTS IN COUNSELING for LPC licensure
Do you hold an active, unrestricted license as a professional counselor (LPC) or marriage and family therapist
(LMFT) in Commonwealth of Virginia?
Yes No
Do you have two (2) years of post-licensure clinical experience?
If a portion of your post-license experience was in another state, please indicate the number of years you held
LPC or LMFT licensure in another jurisdiction?
Yes No
Have you received professional training in supervision, consisting of three credit hours, or 4.0 quarter hours in
graduate-level coursework in supervision, or at least 20 hours of continuing education in supervision offered
by a provider approved under Regulations18VAC115-20-106?
Please provide a copy of your official transcripts showing credit hours earned or certificate(s) of
participation.
Yes No
Revised 2/2020
9960 Mayland Drive, Suite 300
Henrico, VA 23233-1463
www.dhp.virginia.gov/counseling
Email: coun@dhp.virginia.gov
(804) 367-4610 (Tel)
(804) 767-6225 (Fax)
APPLICATION FOR BOARD APPROVED LPC, LMFT AND LSATP SUPERVISOR-Page 2
Supervisor Requirements to supervise RESIDENTS IN MARRIAGE AND FAMILY THERAPY
for LMFT licensure
Do you hold an active, unrestricted license as a marriage and family therapist (LMFT) or a professional
counselor (LPC) in Commonwealth of Virginia?
Yes No
Do you have two (2) years of post-licensure marriage and family therapy experience?
If a portion of your post-license experience was in another state, please indicate the number of years you held
LMFT or LPC licensure in another jurisdiction?
Yes No
graduate-level coursework in supervision, or at least 20 hours of continuing education in supervision offered
by a provider approved under Regulations 18VAC115-50-96?
Please provide a copy of your official transcripts showing credit hours earned or certificate(s) of
participation.
Yes No
Supervisor Requirements to supervise RESIDENTS IN SUBSTANCE ABUSE TREATMENT
PRACTITIONERS for LSATP licensure
Do you hold an active, unrestricted license as a professional counselor (LPC) or substance abuse treatment
practitioner (LSATP) in Commonwealth of Virginia?
Yes No
Do you have two (2) years of post-licensure substance abuse treatment experience?
If a portion of your post-license experience was in another state, please indicate the number of years you held
Yes No
Do you have at least 100 hours of didactic instruction in substance abuse treatment?
Please provide a copy of your official transcripts showing credit hours earned in substance abuse
treatment or certificate(s) of participation in substance abuse treatment.
Yes No
Have you received professional training in supervision, consisting of three credit hours or 4.0 quarter hours in
graduate-level coursework in supervision or at least 20 hours of continuing education in supervision offered
by a provider approved under 18VAC115-60-116?
Please provide a copy of your official transcripts showing credit hours earned or certificate(s) of
participation.
Yes No
I attest that the information contained within the application is true and accurate to the best of my knowledge and belief.
Supervisor Signature:
Date:
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APPLICATION FOR BOARD APPROVED LPC, LMFT AND LSATP (Virginia Department of Motor Vehicles)

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Completed 6 March 2021

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