Professional Reference Form 2/10/2020
Applicant Reference Form
Instructions to the Applicant:
You must submit completed reference forms from
three
professionals who are familiar
with your current work, at least one of which is from a licensed clinical mental health counselor. Type or print your
name and the reference’s name where indicated below, and forward the form to the reference. The completed form
must be returned directly to you in a sealed envelope with the reference’s signature over the seal or sent directly to the
Board. Unsigned forms/envelopes will be returned.
To: __________________________________ Re: _____________________________________
Reference’s name Applicant’s name
To the Reference completing this form:
The above-named individual has made an application for licensure as
a licensed clinical mental health counselor associate, licensed clinical mental health counselor or licensed clinical
mental health counselor supervisor in North Carolina and has listed you as a reference. The licensed clinical mental
health counselor associate has master’s level training and practices counseling only under supervision. The licensed
clinical mental health counselor has master’s level training and engages in independent professional practice. The
licensed clinical mental health counselor supervisor has master’s level training, engages in independent professional
practice, and provides supervision to licensed clinical mental health counselor associates.
So that the Board may have sufficient knowledge to evaluate this applicant’s qualifications, it is seeking the following
specific information from you. Information must be provided on this form, although additional sheets may be attached,
if necessary.
Please type or print. The completed form must be returned directly to the applicant in a sealed
envelope with your signature over the seal or sent directly to the Board
; any unsigned envelopes will be returned
and may delay file review. Original signature is required; faxed copies are not acceptable.
1. The time period (dates) during which you have known the applicant:
2. Your professional relationship with the applicant:
3. Your opinion regarding the applicant’s training, experience, and professional skills:
4. The applicant’s adherence to legal and ethical standards:
5. Areas of concern, further comments, and recommendations to the Board:
___________________________________________ ___________________________________________
Reference’s Name (type or print) Reference’s Signature
__________________ ___________________________________ _________________________
Date E-Mail Address Daytime Telephone Number
________________________________________________________________________________________________
Address City, State, Zip Code
P.O. Box 77819 | Greensboro, North Carolina 27417
