License Verification Form
The applicant is required to complete Secon I of this form and forward to the current licensing board for compleon of
Secon II. The current licensing board should mail to the address listed above.
Board Name ______________________________________________________________________________________________________
________________________________________________________________________________________________________________
Address City/State/ZIP
__________________________________________ ________________________________________
Signature of person compleng form (State Seal) Printed name of person compleng form
__________________________________________ ________________________________________
Ocial Title Date form completed
This version supersedes all previous versions Revised 02/10/2020
Secon I. To be completed by Applicant
Applicant’s Name ____________________________________________________________________________________________
First Middle
Applicant’s License #__________________ State of Issue ______________
Last
Applicant’s SS# ________-_____-________
Years of Experience as an LCMHC ________
Date issued ___________ Type of License ______________________
Academic Instuon ________________________________________________________________________________
Degree ___________________________________________ Ye
ar Conferred __________ Credits Earned __________
I hereby authorize the release of licensure information to the North Carolina Board of Licensed Clinical Mental Health Counselors.
__________________________________________________________ _________________________
Applicant’s Signature Date
Secon II. To be completed by the State Licensing Board where the North Carolina applicant is currently licensed
Title of License _____________________________________________________________________________________
Doe
s this license require supervision in order to pracce? ___ Yes ___No
License status: ___ Acve or ___Inacve Issue date _____________________ Expiraon date __________________
mm/dd/yyyy mm/dd/yyyy
Is this license in good standing? ___ Yes ___No If not, aach explanaon.
License issued by:
___ Examinaon: ___ NCE ___ NCMHCE ___ CRC ___ Other ______________________________
___ Endorsement From what state? ______________________________
___ Grandfathering
Supervised post-degree experience:
Total # of hours required _______________ ___ Su
pervisor license/credenals required __________________________
Total direct counseling hours __
_____________ Total indirect counseling hours _________________
Total individual supervision hours per week ___________ Total group supervision hours per week ___________
Date range of experience: From: ______________________ To: ____________________________
mm/dd/yyyy mm/dd/yyyy
Is there any record of disciplinary acon taken against this licensee? ___ Yes ___No If yes, aach an explanaon.
Do you require vericaon of connuing educaon for licensure renewal? ___ Yes ___No
# of contact hours required _______ # of years in renewal period _______ # of ethics hours required _______
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