Fillable CERTIFICATION OF COUNSELING EDUCATION (Michigan)

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CERTIFICATION OF COUNSELING EDUCATION (Michigan)

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LARA/BPL-COUNSELEDUC (1/20)
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status,
disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.
1 of 3
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 335-0918
www.michigan.gov/bpl
BPLHelp@michigan.gov
CERTIFICATION OF COUNSELING EDUCATION
Authority: 1978 PA 368
This form must be submitted directly to this office by your educational institution. If this form is submitted by the applicant, it will not be accepted.
APPLICANT MUST COMPLETE PAGE 1 OF FORM
Applicant’s Name (First, Middle, Last)
Date of Birth
Address
City
State
Zip Code
Telephone Number
Email Address
Name of Educational Institution
Address of Educational Institution
City
State
Zip Code
Date of Admission
Date Degree Granted
Level of Degree Granted
Discipline/Program Title
LARA/BPL-COUNSELEDUC (1/20)
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status,
disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.
2 of 3
EDUCATIONAL PROGRAM REPRESENTATIVE MUST COMPLETE REMAINDER OF FORM
SECTION 1
PROGRAM REPRESENTATIVE CERTIFICATION
I certify that ______________________
___________________ attended ___________________________________________
(Name of Applicant) (Name of Educational Institution)
from _____________________ to ____________
___________ and was granted a ____________________________________
(Month/Day/Year) (Month/Day/Year) (Level)
degree in ______________________________
_____________. I also certify that the length of this program contained at least
(Discipline/Program Title)
48 semester hours or 72 quarter h
ours. I further certify that this program is accredited by:
CACREP REGIONALLY ACCREDITED BY: _________________________________________________
SECTION 2 MUST BE COMPLETED ONLY FOR EDUCATIONAL PROGRAMS THAT ARE NOT CACREP ACCREDITED.
A program that is not accredited by the Council for the Accreditation of Counseling and Related Educational Programs
(CACREP), must include coursework and training in the diagnosis and treatment of mental and emotional disorders and all other
coursework requirements of CACREP, including practicum and internship requirements.
Please insert below the name of the course(s) and the corresponding course number(s) completed that cover the coursework
requirements. Further, you must send a course description and syllabus for these courses to the Department for review.
Yes No DIAGNOSIS
Course Name: ________________________________________________________ Course #:_________________________
Yes No
TREATMENT OF MENTAL AND EMOTIONAL DISORDERS
Course Name: ________________________________________________________ Course #:_________________________
Yes No
PROFESSIONAL ORIENTATION AND ETHICAL PRACTICE
Course Name: ________________________________________________________ Course #:_________________________
Yes No
SOCIAL AND CULTURAL DIVERSITY
Course Name: _________________________________________________________ Course #:_______________________
Yes No
HUMAN GROWTH AND DEVELOPMENT
Course Name: _________________________________________________________ Course #:_________________
______
LARA/BPL-COUNSELEDUC (1/20)
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status,
disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.
3 of 3
Yes No
CAREER DEVELOPMENT
Course Name: _________________________________________________________ Course #:________________________
Yes No
HELPING RELATIONSHIPS
Course Name: _________________________________________________________ Course #:________________________
Yes
No
GROUP WORK
Course Name: _________________________________________________________ Course #:________________________
Yes
No
ASSESSMENT
Course Name: ______________________________
___________________________ Co
u
r
se
#
:
________________________
Yes
No
RESEARCH AND PROGRAM EVALUATION
Course Name: _________________________________________________________ Course #:_____________
___________
SECTION 3
The
courses taken and degree earned by _____________________________________________ meets the requi
rements of
the
(
Name of Applicant)
_______________________________________________
Date
_______________________________________________
Contact telephone number
(
Seal) If academic institution has no seal, please indicate.
Michigan Public Health Code.
__________________________________________________
Signature of Program Representative
__________________________________________________
Print or type name of Program Representative
__________________________________________________
Print or Type Name of Director or Superintendent
PRACTICUM
Course Name: _________________________________________________________ Course #:________________________
I
NTERNSHIP
Cours
e N
ame: ____________________________
___________________________
__ Course #:________________________
Yes
No
Yes
No
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CERTIFICATION OF COUNSELING EDUCATION (Michigan)

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Completed 9 February 2021

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