LARA/BPL-COUNSELEXP (10/18)
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.
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 335-0918
www.michigan.gov/bpl
BPLHelp@michigan.gov
COUNSELING WORK EXPERIENCE
Authority: 1978 PA 368
This form must be submitted directly to this office by your supervisor. If this form is submitted by the applicant, it will not be accepted.
Section of Form to be Completed by Applicant:
Applicant’s Name (First, Middle, Last)
Date of Birth
Telephone Number
Limited License Professional Counselor #
Remainder of Form to be Completed by Supervisor:
CERTIFICATION AND SIGNATURE
I certify the applicant named above practiced counseling under my supervision from _____________________________
to
(Month/Day/Year)
_____________________________
for a total of _________________ hours including __________________ hours in my immediate
(Month/Day/Year)
physical presence. I also certify I have received training in the function of supervision pursuant to Administrative Rule 338.1757 and
conducted supervision pursuant to applicable statutes and administrative rules. I was available on a regularly scheduled basis to
review the practice of the applicant, to provide consultation, to review records, to further educate the applicant and there was
continuous availability of direct communication in person or by radio, telephone or telecommunication.
_________________________________________________ ____________________________________________
Signature of Supervisor Date
_____________________________________________________
Print or Type Name of Supervisor (Seal) If hospital has no seal, please indicate.
_____________________________________________
_
Michigan Permanent ID Number, if applicable
_____________________________________________
_ ____________________________________________
State licensed, if not Michigan Type of License or Certificate
click to sign
signature
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