Fillable South Carolina Application and Education Review (Center for Credentialing & Education)

Fill Online, Printable, Fillable, Blank South Carolina Application and Education Review (Center for Credentialing & Education) Form

Use Fill to complete blank online CENTER FOR CREDENTIALING & EDUCATION pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

South Carolina Application and Education Review (Center for Credentialing & Education)

On average this form takes 89 minutes to complete

The South Carolina Application and Education Review (Center for Credentialing & Education) form is 48 pages long and contains:

  • 2 signatures
  • 53 check-boxes
  • 323 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Center for Credentialing & Education forms online.

BROWSE CENTER FOR CREDENTIALING & EDUCATION FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1
3 TERRACE WAY
GREENSBORO, NORTH CAROLINA 27403-3660 USA
TEL: 336-482-2856 * FAX: 336-482-2852
www.cce-global.org * cce@cce-global.org
The Center for Credentialing & Education, Inc. (CCE
) values diversity.
There are no barriers to certication on the basis of gender, race, creed, age, sexual orientation or national origin.
CCE and NBCC are registered trade and service marks of the National Board for Certied Counselors, Inc.
South Carolina
Application and Education Review
for Licensure as a Professional Counselor
or Professional Counselor Associate
2020 Application
This application form is interactive.
Download the form to your computer to ll it out.
2
The Center for Credentialing & Education, Inc. (CCE), an afliate of the National Board for Certied Counselors, Inc
(NBCC) has been contracted by the South Carolina Board of Examiners for Licensure of Professional Counselors,
Marriage and Family Therapists, Addiction Counselors, and Psycho-Educational Specialists to accept completed
applications and review the educational experience of applicants for licensure as professional counselors and professional
counselor associates.
CCE
accepts all application documents and reviews the educational experience of applicants for the South Carolina Board
of Examiners. Please note that CCE cannot return or duplicate an application. Prior to submitting your application to CCE,
please make a copy of it for your records.
In addition to the information in this application booklet, you are advised to review the:
1. South Carolina Statutory Authority: 1976 Code Section 40-75-05, et seq.
2. South Carolina Code of Regulations and Code of Ethics, Chapter 36
3. South Carolina supervision policy and guidelines
4. South Carolina list of licensed professional counselor supervisors (LPC/S)
These documents are available at https://llr.sc.gov/
The South Carolina regulations list the requirements for licensure as a professional counselor associate and a
professional counselor by endorsement from another state and should be reviewed carefully by every applicant prior
to completing the application.
3
General: Candidates for initial licensure must make application and meet the South Carolina Board of Examiners for
Licensure of Professional Counselors, Marriage and Family Therapists, Addiction Counselors, and Psycho-Educational
Specialists ("Board") licensing requirements. CCE is the contracted agent for the Board to review all applications for
licensure in South Carolina for compliance with education and examination requirements. CCE reviews applications in
regards to criteria set out in the South Carolina Code of Laws and Regulations. These requirements must be met in full,
and are outlined fully on pages 9-12 of this packet.
Examination: All licensure candidates must take and pass either the National Counselor Examination for Licensure and
Certification (NCE) or National Clinical Mental Health Counseling Examination (NCMHCE). Both of these examinations
are administered by NBCC. Once your educational experience has been approved, you will be sent a letter with
examination registration information. Additional information about the examination can be found on page 13 of this
packet. You will receive your results immediately following the exam; however, these results are not official. Allow four
to six weeks for NBCC to send CCE the official exam score reports.
Candidates who have already taken and passed either the NCE or NCMHCE must indicate the exam taken and date
passed on page 16 of the application. You will need to request that your scores be sent to CCE or enclose a copy of your
official score report with your application. Visit www.nbcc.org/Exams/ScoreReport for information about obtaining
your score report.
Application completion process: You are allowed three years from the date CCE receives your initial application to
complete all requirements (including passing the exam) and obtain licensure. If licensure is not obtained within three
years, you will be required to submit a new application, fees, and up-to-date credentials to meet the licensure requirements
that are in effect at the time of reapplication.
Right to Board Review: CCE only provides an initial review regarding whether or not an applicant meets the established
education and examination criteria. You will be notified if, from the information submitted, it does not appear that your
qualifications meet these requirements, and what deficiencies have been identified. You can request that CCE undertake a
second review by submitting a letter to CCE explaining your request and including any supporting or additional
documentation that is related to your request. If, after a second review, it still does not appear that your qualifications
meet the requirements, you may request to appear before the Board by submitting your request to CCE in writing. CCE
will forward your request, file and additional information to the South Carolina Board of Examiners. The SC Board will
contact you regarding next steps.
Licensure approval: Candidates will have their file sent to the SC Board for final review for approval of licensure once
CCE deems their educational experience meets requirements and CCE is notified that the Candidate has received a
passing score on an eligible examination. CCE will send the candidate a letter indicating the date their file was forwarded
to the SC Board. The SC Board of Examiners will proceed with the final review of the application. A candidate is not
licensed as a licensed professional counselor intern or a professional counselor by endorsement from another state until
official notification is received directly from the South Carolina Board of Examiners and a license is issued.
Once a candidate’s file is received, the South Carolina Board of Examiners will review the file and send the official board
results within four to six weeks. The letter will contain useful information about the license and will include the license
activation fee amount that must be remitted to the Board in order to activate the license. Once the license activation fees
are received and processed, the candidate will receive a certificate and license card. If an application has been approved
for an intern license, the candidate must receive the license to practice in the state of South Carolina before beginning the
required 120 hours of supervision.
Degree, coursework and practicum requirements: The educational requirements are outlined on page 10 of this
packet. As states differ in requirements for degrees and coursework, some applicants may need to take additional
coursework in order to meet the South Carolina requirements. Post licensure experience cannot be substituted for required
coursework.
South Carolina LPC Review
General Information for All Applicants
4
General: Candidates for initial licensure must make application and meet the South Carolina Board of Examiners for
Licensure of Professional Counselors, Marriage and Family Therapists, Addiction Counselors, and Psycho-Educational
Specialists ("Board") licensing requirements. CCE is the contracted agent for the Board to review all applications for
licensure in South Carolina for compliance with education and examination requirements. CCE reviews applications in
regards to criteria set out in the South Carolina Code of Laws and Regulations. These requirements must be met in full,
and are outlined fully on pages 9-12 of this packet.
Practice as a licensed professional counselor intern: The Code of Regulations, Chapter 36, Section 36-05 states
that evidence of a minimum of 1,500 hours of supervised clinical experience (direct client counseling contact hours) in the
practice of professional counseling must be performed over a period of not less than two years under the supervision of
a licensed professional counselor supervisor or other qualified licensed mental health practitioner (licensed psychologist,
licensed medical doctor such as a psychiatrist). LPC supervisor candidates are also acceptable. Of these 1,500 hours of
direct counseling with individuals, couples, families or groups, a minimum of 120 hours are to be spent in immediate
supervision with a licensed professional counselor supervisor/supervisor candidate.
Logs of hours for the 1,500 hours of supervised clinical experience are not required by the Board; however, it is suggested
that you maintain a log for your own records. The intern license is issued for two years and is structured to allow a
reasonable period to complete all requirements of supervision for full licensure. The SC Practice act statute requires
individuals to hold a license to practice in South Carolina; therefore, the professional counselor intern license is mandatory.
Supervision requirements: A Plan and Arrangements for Clinical Supervision of Post-Master’s Clinical Experience in
Counseling (pages 22-24) is a required document that must be submitted with the application for licensed professional
counselor intern candidates. The supervision policies, guidelines and list of supervisors are available at www.llr.state.
sc.us/pol/counselors. Select “Applications/Forms” from the right-hand side, scroll down to “Professional Counselor (LPC)
and Intern Application Packet,” and select “List of Supervisors.” The 120 hours of immediate supervision can only be
obtained from a South Carolina licensed professional counselor supervisor or supervisor candidate.
• This is a plan that is used to acknowledge and verify that arrangements have been made with a South Carolina LPC
supervisor/supervisor candidate to obtain 120 hours of supervision. These hours will not begin until after you
have obtained a license to practice in South Carolina as a professional counselor
intern, therefore the “From/
To” dates of supervision can be estimated to begin approximately three months after the date of your application to
allow time for the credential review/passage of the exam/obtaining a license to practice.
• The “To” date should reflect a two-year period from the beginning date, since the LPC associate licensure period is
structured for two years.
• Section 1 “Total hours” should reflect 1,380 hours.
• The “From/To” dates for both section 1 and section 2 should reflect the same date ranges.
Practicum/Internship: Specific training is required for LPC/As who wish to assess and treat serious problems,
as categorized in standard diagnostic nomenclature. This specific training includes the required coursework in
psychopathology and/or diagnostics of psychopathology as outlined for all applicants in Section 36-04.1 of the South
Carolina Code of Regulations
as well as completion of the specific practicum and internship as follows:
(1) A practicum of 100 hours as part of a degree program that dealt directly with the assessment and treatment of
serious problems as categorized in standard diagnostic
nomenclature; and
(2) An internship, as part of a degree program, of at least 600 hours under the supervision of a qualified licensed
mental health practitioner where experience assessing and treating clients with serious problems as categorized in
standard diagnostic nomenclature is obtained.
The internship of at least 600 hours is not required to obtain licensure as a LPC associate(only a 100-hour
practicum is required). The experience gained in the 600-hour internship determines the level of practice that you
can perform once licensed as an LPC associate.
This specific training must be documented on the Practicum/Internship Verification form found on page 19 of this packet.
Those applicants with only a 100-hour counseling practicum will need to move slowly into assessing and treating serious
problems under the supervision of qualified supervisors during their LPC/A licensure.
South Carolina LPC Review
Professional Counselor Associate Applicants
5
All of the following materials must be received by CCE before the professional counselor associate application review
and licensure process can begin:
□ Application and Education Review form (pages 14-21)
The Affidavit of Eligibility (pages 17-18) must be completed, signed, and notarized. A copy of your
driver’s license or other identification (specified on page 17) AND a copy of your social security card
must be provided for identification purposes. Refer to Section B.1 on the Affidavit of Eligibility form.
Applications will be returned if incomplete or the Affidavit of Eligibility is incomplete.
□ Application and education review fee of $170
This fee is nonrefundable. CCE accepts payment via credit card, personal check, money order, or cashier’s
check. Make payable to (CCE).
□ Official transcript
Contact the registrar’s office at your graduate university/college to order an official transcript documenting
completion of a graduate degree primarily in counseling or a related discipline with a minimum of 48
graduate semester hours. (Do not include undergraduate transcripts.) Official transcripts from all graduate
institutions must be provided to verify the coursework/practicum/internship information that is entered on
the application. South Carolina will accept a sealed official transcript included with the application packet.
Transcripts mailed from the registrar’s office should be sent to:
CCE-SC Review
3 Terrace Way
Greensboro, NC 27403
□ Coursework descriptions
Coursework descriptions photocopied from the catalogue for the year in which the courses were taken must
be submitted with the application or sent to CCE by the university. Some universities have these available
on their Web sites. Course descriptions must be submitted for all core courses in addition to the descriptions
for the practicum/internship. A syllabus is also acceptable.
□ Plan and arrangements for clinical supervision of post-master’s clinical experience in
counseling (pages 22-24)
This form must be completed by both you and your LPC supervisor/supervisor candidate. See page 3 for
more information.
□ Examination scores (required only if you answer “yes” to question 5 on page 15
A photocopy of your official score report is acceptable. If you do not have a copy to submit, visit
www.nbcc.org/Exams/ScoreReport to request a score verification.
NBCC can send the score verification directly to CCE by mailing it to:
CCE-SC Review
3 Terrace Way
Greensboro, NC 27403
South Carolina LPC Review
Professional Counselor Associate Checklist
6
All of the following materials must be received by CCE before the professional counselor application review and licensure
by endorsement process can begin:
□ Application and Education Review Form (pages 14-21)
The Affidavit of Eligibility (pages 17-18) must be completed, signed, and notarized. A copy of your
driver’s license or other identification (specified on page 17) AND a copy of your social security card
must be provided. Refer to Section B.1 on the Affidavit of Eligibility form. Applications will be returned
if incomplete or the Affidavit of Eligibility is incomplete.
□ Application and Education Review Fee of $170
This fee is nonrefundable. CCE accepts payment via credit card, personal check, money order or cashier’s
check. Make payable to CCE.
□ Official Transcript
Contact the registrar’s office at your graduate university/college to order an official transcript documenting
completion of a graduate degree primarily in counseling or a related discipline with a minimum of 48
graduate semester hours. Do not include undergraduate transcripts. Official transcripts from all graduate
institutions must be provided to verify the coursework/practicum/internship information that is entered on
the application. South Carolina will accept an official transcript included with the application packets.
Transcripts mailed from the registrar’s office should be sent to:
CCE-SC Review
3 Terrace Way
Greensboro, NC 27403
□ Coursework Descriptions
Coursework descriptions photocopied from the catalogue for the year in which the courses were taken must
be submitted with the application or sent to CCE by the university. Some universities have these available
on their Web sites. Course descriptions must be submitted for all core courses in addition to the descriptions
for the practicum/internship. A syllabus is also acceptable.
□ Verification of Licensure (page 29)
This form must be completed by the state or jurisdiction in which you are licensed and mailed directly to:
CCE-SC Review
3 Terrace Way
Greensboro, NC 27403
Licensed professional counselors who have an active, current and unrestricted license in another state may be eligible for
licensure by endorsement in the state of South Carolina. These applicants must meet the licensure requirements that are
currently in place in South Carolina, including degree, coursework, practicum and post-master’s supervised experience.
The license you hold outside South Carolina must remain active throughout this application process.
Post-master’s supervised experience: Refer to page 25 for specic requirements for postgraduate supervised
experience. CCE will review your education and assure all required forms are complete. Once your education has been
tentatively approved by CCE, your le will be forwarded to the South Carolina licensing board for a nal review of both
your education and your supervision. All questions regarding the required education should be directed to CCE. Questions
regarding the required supervision should be directed to the South Carolina Board of Examiners administrative ofce at
803-896-4658. Applicants are not licensed as professional counselors until they receive ofcial notication directly from
the South Carolina licensing board.
South Carolina LPC Review
Licensure By Endorsement Checklist
7
□ Log for Clinical Supervision of Post-Master’s Clinical Experience (pages 25-26)
This form must be completed by the applicant.
□ Examination Scores (required only if you answer “yes” to question 5 on page 15)
A photocopy of your official score report is acceptable. If you do not have a copy to submit, visit
www.nbcc.org/Exam/ScoreVerificationReport to request a score verification.
NBCC can send the score verification directly to CCE at:
CCE-SC Review
3 Terrace Way
Greensboro, NC 27403
□ Confirmation of Clinical Supervision Form (pages 27-28) Include this form with your supervisor’s
signature or have your state’s licensing board office furnish proof of your supervised experience. This
documentation must be sent directly to CCE from the licensing board office.
□ Copy of Your License
Your license must remain active, current, and unrestricted throughout this application process.
8
If you received your degree or completed relevant master’s or doctoral coursework outside the United States, you
will need to have an international transcript evaluation completed prior to submitting an application for licensure. The
transcript evaluation and course descriptions will be reviewed by CCE to determine whether the degree, coursework and
practicum requirements have been met.
The official, sealed evaluation must be submitted with your application.
International transcript evaluations must be completed by one of the following:
Educational Credential Evaluators, Inc. (ECE)
P. O. Box 514070
Milwaukee, WI 53203-3470
Telephone: 414-289-3400
Web site: www.ece.org
E-mail: eval@ece.org
World Education Services, Inc. (WES)
P. O. Box 745 Old Chelsea Station
New York, NY 10113-0745
Telephone: 800-937-3895
Web site: http://www.wes.org
E-mail: info@wes.org
American Association of Collegiate
Registrars & Admissions Ofces (AACRAO)
1 Dupont Circle NW
Suite 520
Washington, DC 20036
Telephone: 202-296-3359
Web site: www.aacrao.org
South Carolina LPC Review
Coursework/Degrees Completed
Outside the United States
9
Graduate Degree – Applicants must submit evidence of successful completion of a graduate degree (master’s degree,
specialist degree or doctoral degree) with a minimum of 48 graduate semester hours or 72 quarter hours primarily in
counseling or a related discipline.
Required Graduate-Level Coursework – The applicant’s graduate transcript(s) must demonstrate successful
completion of the following graduate coursework (each course must be a minimum of three semester hours or 4.5 quarter
hours. One course cannot be used to satisfy two different categories). All coursework must be completed at a college or
university accredited by the Commission on Colleges of the Southern Association of Colleges and Schools or one of the
following accrediting bodies:
• Middle States Association of Schools and Colleges
• North Central Association of Colleges and Schools
• Northwest Commission on Colleges and Universities
• Western Association of Schools and Colleges
• New England Association of Schools and Colleges
• Association of Theological Schools
By law, all applicants must have earned a minimum of 48 semester hours or 72 quarter hours in graduate-level counseling
or a related discipline, and the applicant must demonstrate on graduate transcript successful completion of a three-
semester-hour or a 4.5-quarter-hour graduate-level course in each of the following 9 areas and completion of a 100-hour
counseling practicum:
1. Human Growth and Development
2. Social and Cultural Foundations
3. The Helping Relationship
4. Group Dynamics, Processing and Counseling
5. Lifestyle and Career Development
6. Appraisal of Individuals
7. Research and Evaluation
8. Professional Orientation
9. Psychopathology or Diagnostics of
Psychopathology
This course of study may be completed during the qualifying degree program, or additional graduate-level coursework
may be completed if necessary.
Practicum – A minimum 100-hour supervised counseling practicum is required. It must provide supervised field
placement(s) in an appropriate counseling setting for academic credit as part of the degree program.
Please note: If, as an LPC/A, an applicant would like to assess and treat serious problems as categorized in standard
nomenclature, they must have a practicum that dealt directly with the assessment and treatment of serious problems as
well as a 600-hour supervised counseling internship dealing with serious problems as part of the degree program.
Please see pages 10-12 for
detailed coursework descriptions.
South Carolina LPC Review
Educational Experience Requirements for
Licensure as a Professional Counselor or
Professional Counselor Associate
10
DEFINITION OF CATEGORIES FOR REQUIRED COURSEWORK
Human Growth and Development
Studies that provide an understanding of the nature and needs of individuals at all developmental levels, normal and
abnormal human behavior, personality theory, and learning theory within cultural contexts. Studies in this area include but
are not limited to:
a. Theories of individual and family development and transitions across the life span;
b. Theories of learning and personality development;
c. Human behavior, including an understanding of developmental crises, disability, addictive behavior,
psychopathology and environmental factors as they affect both normal and abnormal behavior;
d. Strategies for facilitating development over the life span; and
e. Ethical considerations
Social and Cultural Foundations
Studies that provide an understanding of societal changes and trends in a multicultural and diverse society, human roles,
societal subgroups, social mores and interaction patterns, and differing lifestyles. Studies in this area include but are not
limited to:
a. Multicultural and pluralistic trends including characteristics and concerns of diverse groups;
b. Attitudes and behavior based on such factors as age, race, religious preference, gender, socioeconomic status and
intellectual ability;
c. Individual, family and group strategies with diverse populations; and
d. Ethical considerations.
The Helping Relationship
Studies that provide an understanding of philosophic bases of helping processes, counseling theories and their
applications, helping skills, consultation theories and applications, helper self-understanding and self-development, and
facilitation of client or consultee change. Studies in this area include but are not limited to:
a. Counseling and consultation theories including both individual and systems perspectives as well as coverage of
relevant research and factors considered in applications;
b. Basic interviewing, assessment and counseling skills;
c. Counselor or consultant characteristics and behaviors that inuence helping processes, including age, gender,
ethnic differences, verbal and nonverbal behaviors and personal characteristics, orientations, and skills;
d. Client or consultee characteristics and behaviors that inuence helping processes, including age, gender, ethnic
differences, verbal and nonverbal behaviors and personal characteristics, orientations, and skills; and
e. Ethical considerations.
Group Dynamics, Processing and Counseling
Studies that provide an understanding of group development, dynamics and counseling theories; group leadership styles;
group counseling methods and skills; and other group approaches. Studies in this area include, but are not limited to:
a. Principles of group dynamics, including group process components, developmental stage theories, and group
members’ roles and behaviors;
b. Group leadership styles and approaches, including characteristics of various types of group leaders and
leadership styles;
c. Theories of group counseling, including commonalities, distinguishing characteristics, and pertinent research and
literature;
d. Group counseling methods, including group counselor orientations and behaviors, ethical standards, appropriate
selection criteria and methods of evaluation of effectiveness;
11
e. Approaches used for other types of group work, including task groups, prevention groups, support groups, and
therapy groups; and
f. Ethical considerations.
Lifestyle and Career Development
Studies that provide understanding of career development theories, occupational and educational information sources
and systems; career and leisure counseling, guidance, and education; lifestyle and career decision-making; and career
development program planning, resources, and evaluation. Studies in this area include but are not limited to:
a. Career development theories and decision-making models;
b. Career, vocational, educational, and labor market information resources; visual and print media, and computer-
based career information systems;
c. Career development program planning, organization, implementation, administration and evaluation;
d. Interrelationships among work, family, and other life roles and factors, including multicultural and gender issues
as related to career development;
e. Career and educational placement, follow-up and evaluation;
f. Assessment instruments and techniques relevant to career planning and decision-making;
g. Computer-based career development applications and strategies, including computer-assisted career
guidance systems;
h. Career counseling processes, techniques and resources, including those applicable to specic populations; and
i. Ethical considerations.
Appraisal of Individuals
Studies that provide an understanding of group and individual educational and psychometric theories and approaches to
appraisal, data and information-gathering methods, validity and reliability; psychometric statistics; factors influencing
appraisals; use of appraisal results in helping processes; and understanding of individual and group approaches to
assessment and evaluation. Studies in this area include but are not limited to:
a. Theoretical and historical bases for assessment techniques;
b. Validity, including evidence for establishing content, construct and empirical validity;
c. Reliability, including methods of establishing stability, internal and equivalence reliability;
d. Appraisal methods, including environmental assessment, performance assessment, individual and group test
inventory methods, behavioral observations, and computer-managed and computer-assisted methods;
e. Psychometric statistics, including types of assessment scores, measures of central tendency, indices of variability,
standard errors and correlations;
f. Age, gender, ethnicity, language, disability and culture factors related to the assessment and evaluation of
individuals and groups;
g. Strategies for selecting, administering, interpreting and using assessment and evaluation instruments and
techniques in counseling; and
h. Ethical consideration in appraisal.
Research and Evaluation
Studies that provide an understanding of types of research methods, basic statistics, research report development, research
implementation, program evaluation, needs assessment, and ethical and legal considerations. Studies in this area include
but are not limited to:
a. Basic types of research methods to include qualitative and quantitative research designs;
b. Basic parametric and nonparametric statistics;
c. Principles, practices and applications of needs assessment and program evaluation;
d. Uses of computers for data management and analysis; and
e. Ethical and legal considerations in research.
12
Professional Orientation
Studies that provide an understanding of professional roles and functions, professional goals and objectives, professional
organizations and associations, professional history and trends, ethical and legal standards, professional preparation
standards, and professional credentialing. Studies in this area include but are not limited to:
a. History of the helping profession, including signicant factors and events;
b. Professional roles and functions, including similarities and differences with other types of professionals;
c. Professional organizations, primarily the American Counseling Association (ACA), its divisions, branches and
afliates, including membership benets, activities, services to members and current emphases;
d. Ethical standards of the ACA and related entities, ethical and legal issues and their applications to various
professional activities (e.g. appraisal, group work);
e. Professional preparation standards, their evolution and current applications;
f. Professional credentialing including certication, licensure and accreditation practices and standards, and the
effects of public policy on these issues; and
g. Public policy processes including the role of the professional counselor in advocating on behalf of the profession
and its clientele.
Psychopathology
Studies that provide an understanding of psychopathology, abnormal psychology, abnormal behavior, etiology dynamics
and treatment of abnormal behavior. Studies in this area include but are not limited to:
a. The understanding of various forms of abnormal behavior and psychopathology in children, adolescents, and
adults;
b. Focus on the etiology and morbidity of differing mental disorders;
c. Assessment techniques when evaluating psychological disorders, including personality and behavior;
d. Evaluate the psychometric properties of personality and behavior assessment instruments;
e. Determine the benets and limitations of assessment, including current legal and ethical issues;
f. Determine how to integrate information from various sources in order to more fully describe personality and
behavioral patterns;
g. Introduction to the science and art of clinical assessment as a foundation for the actual practice of assessment in
school and community mental health settings;
h. Practical training in the process of clinical assessment as associated with the specic disorders, which is focused
on the use of assessment techniques in a professionally and ethically responsible manner; and
i. Focus on the serious problems, other than adjustment disorders and V codes and codes that are assigned to normal
lifecycle transitional conicts. Serious problems are dened in standard diagnostic nomenclature (Diagnostic and
Statistical Manual of Mental Disorders).
Diagnostics of Psychopathology
Studies that provide an understanding of the diagnostics of psychopathology. Studies in this area include but are not
limited to:
a. Use of the DSM in relation to the psychology of deviant or abnormal behavior;
b. The understanding of the history and theories of abnormal psychology in the eld through lecture, readings, the
Internet, group discussions, and research;
c. The understanding of diagnoses in the version of the DSM that was current when the course was taken;
d. The application of this knowledge through exercises, assignments, class participation and videotaped role-plays;
e. The application of this knowledge through assessment, treatment plans, counseling, projects and
presentations; and
f. Counseling theory, diagnosis of DSM disorders, techniques and interventions.
13
A candidate may submit an application at any time. It will take approximately six weeks from the date of receipt for the
initial application review to be completed. Upon CCE’s tentative approval of your application, registration materials will
be forwarded to you and you will be eligible to register for the NCE or the NCMHCE. These examinations are offered
through NBCC.
Both examinations are administered via computer-based testing (CBT) at more than 900 Pearson Vue testing centers
located throughout the United States. Testing is normally the first two full weeks of each month, Monday through
Saturday, at 8 a.m. and 5:30 p.m. Exams are administered by appointment only, and are scheduled on a first-come, first-
served basis. Registration information will be forwarded to you upon determination of eligibility.
Note: If you took the NCE or NCMHCE for licensure in another state or for national certification, you will need to submit
a photocopy of your official exam results. If you do not have a copy, you will need to submit a score verification request to
NBCC. Contact NBCC at 336-547-0607 or http://www.nbcc.org/Exams/ScoreReport for more information.
FEES
$170
Application and Education Review Fee:
(submitted with this application and paid to CCE)
NBCC Examination Fee (paid to NBCC):
$
27
5
Associate Licensure Fee (paid to the South Carolina Board of Examiners): $150
When licensure is granted by the South Carolina board, there will be a fee of $150 for the two-year professional counselor
associate license. A prorated license fee will be required for the professional counselor by endorsement license.
The application and education review fee and the examination fee are nonrefundable and nontransferable. The application
and education review fee must accompany a completed application. CCE accepts payment via credit card, personal check,
money order or cashier’s check. Payment must be made to CCE.
HOW TO CONTACT CCE
Telephone: 888-817-8283, toll-free; 8:30 a.m. to 5 p.m. Eastern time
E-mail: cce@cce-global.org
Fax: 336-482-2852
Send this application and payment to: CCE P.O. Box 63223 Charlotte, NC 28263-3223
Send other written correspondence to: CCE-SC Review 3 Terrace Way Greensboro, NC 27403-3660
When we receive your application, you should receive a response regarding your application review within six
weeks. Applications and any supplemental material are reviewed in the order in which they are received. To protect
applicants from miscommunication or misinformation, we require applicants with questions regarding their personal
circumstances to communicate in writing. We accept these questions via e-mail, postal mail and fax. We review
applications and respond to questions in the order in which they are received. When your application arrives at CCE, if
any of the required documents are missing or incomplete (for example: course descriptions, supervision plan), you will
be notified in writing of the deficiency within six weeks. When the required documentation arrives, your application will
be placed back in the queue to be reviewed. We will contact you within six weeks of receiving the additional
documentation.
South Carolina LPC Review
Application Review and
Examination Registration Timeline
14
South Carolina Board of Examiners
for Licensure of Professional Counselors,
Marriage and Family Therapists,
Addiction Counselors, and Psycho-
Educational Specialists
Mail application to:
CCE
P.O. Box 63223
Charlotte, NC 28263-3223
INSTRUCTIONS
1. The applicant is required to carefully read the application and requirements before completing this application.
Applications must be complete prior to submission. The review fee must also be included. Incomplete
applications will not be reviewed. CCE accepts payment in the form of a credit card, money order, cashier’s
check or personal check. All fees are nonrefundable and nontransferable. This application will remain open
for three years from the initial date submitted to CCE.
2. Type or print all information.
3. For questions, contact CCE at 888-817-8283.
CHECK ONE.
Applying for Licensure as a Professional Counselor Associate
Applying for Licensure by Endorsement From Another State
1. Title: □ Dr. □ Mr. □ Ms. □ Mrs. □ _____________________
Name (last, rst, middle initial): _______________________________________________________________________
Please list any other names used on transcripts, licenses, etc.: ____________________________________________
______________________________________________________________________________________________
2. Home Address (physical address, not P.O. Box): ______________________________________________________
City: _____________________________________ State: _____________ ZIP Code (+4): ________________
County: ___________________________________ Home Telephone: ___________________________________
Home E-mail: _________________________________________________________________________________
Cellphone: ____________________________ Home Congressional District Number: _____________________
3. Employer Name (if not currently employed, please write “NA”):
_____________________________________________________________________________________________
Employer Address: _____________________________________________________________________________
City: ___________________________________ State: ______________ ZIP Code (+4): _______________
County: _______________________________ Telephone (direct dial, if possible): ________________________
Work E-mail: _________________________________________________________________________________
South Carolina LPC Review
Application and Education Review Form
This application form is interactive. Download the form to your computer to ll it out.
15
8. Personal History Information: If yes to any of the questions below, please explain fully in a letter and attach.
a. Have you ever been convicted of a crime (other than a minor trafc violation)?
b. Have you ever had any application for any professional license, certication or
registration refused or denied by any licensing authority?
c. Have you ever been refused or denied the privilege of taking an examination required
or any professional license?
d. Have you ever been the subject of disciplinary action with regard to a license or been revoked
or sanctioned by any licensing authority, association, licensed facility, or staff of such facility?
e. Have your privileges ever been restricted or terminated by any association, licensed facility,
or staff of such facility, or have you ever voluntarily or involuntarily resigned or withdrawn
from such association or facility to avoid imposition of such measures?
f. To your knowledge, have any unresolved or pending complaints ever been led against
you with any federal or state agency, professional association, licensed hospital or clinic,
or staff of such hospital or clinic?
NoYes
NoYes
NoYes
NoYes
NoYes
Yes No
7. If you have been or are currently licensed (in any profession) in any other state(s), please document below:
State
License
Number
Date
Licensed
Expiration
Date
Lapsed
Revoked/
Suspended
Probation
Profession/
Field
4. Gender: □ Male □ Female
Date of Birth: Month: ___________ Day: _______ Year: ____________
Race: □ Caucasian/White □ African American/Black □ American Indian
□ Asian/Oriental □ Hispanic/Spanish Origin □ Other
5. Have you taken and passed the National Counselor Examination for Licensure and Certication (NCE) or the National
Clinical Mental Health Counseling Examination (NCMHCE)? □ Yes □ No
If “yes,” indicate exam taken: _____________________________________ Date Taken: ___________________
Attach a copy of exam score report (if available).
Education College/University
Degree Date Conferred Major
Credits Earned
Master’s Degree
Post-Master’s
Coursework
Doctoral Degree
6. Education: All applicants must complete the information below and must include an ofcial sealed transcript
from all graduate institutions attended. Do not send undergraduate transcripts. If you completed coursework after
your master’s degree to meet the requirements, ofcial sealed transcripts from those institutions must be provided.
16
g. Have you ever been arrested, charged or convicted (including a nolo contendere
plea or guilty plea) in any state or federal court (other than minor trafc violations)
whether or not sentence was imposed or suspended?
If yes, attach a certied copy of the court records regarding your
conviction, the nature of the offense, and date of discharge (if applicable).
Also, you must have a statement from the probation or parole ofcer sent
directly to CCE from the above-mentioned authorities.
h. Currently, are you being treated or within the last ve years, have you been treated
for drug or alcohol addiction that might interfere with your ability to competently and
safely perform the essential functions of practice?
i. Have you ever been court martialed or discharged other than honorably from the
armed service?
j. Currently or within the last ve years, have you been treated for any physical, mental
or emotional condition that might interfere with your ability to competently and safely
perform the essential functions of practice?
k. Currently or within the last ve years, have you developed any disease or conditions,
physical, mental or emotional that might interfere with your ability to competently and
safely perform the essential functions of practice?
Yes No
Yes No
Yes No
Yes No
Yes No
Rev: 02-02-2015
STATE OF SOUTH CAROLINA
DEPARTMENT OF LABOR, LICENSING AND REGULATION
VERIFICATION OF LAWFUL PRESENCE IN THE UNITED STATES
AFFIDAVIT OF ELIGIBILITY
Pursuant to Section 8-29-10, et seq. of the South Carolina Code of Laws (1976, as amended), the Department
of Labor, Licensing and Regulation must verify that any person who applies for a South Carolina license is
lawfully present in the United States. Complete and sign this affidavit of eligibility. The information provided is
subject to verification.
Section A: LAWFUL PRESENCE in the United States.
The undersigned _ _____, of
_
_
(Print clearly First, Middle, and Last name) (Home Address, City, State, and Zip Code)
being first duly sworn deposes and states as follows:
Section B: ATTESTATION.
I understand that in accordance with section 8-29-10 of the South Carolina Code of Laws, a person who
knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall, in
addition to other sanctions imposed by this State or the United States, be guilty of a felony, and upon
conviction must be fined and/or imprisoned for not more than 5 years (or both).
I understand that the representations made in this Affidavit shall apply through any license(s) or renewals
issued, and that I shall have an affirmative duty to immediately advise the Department of Labor, Licensing and
Regulation of any change of my immigration or citizenship status.
I swear and attest the information contained herein is true and correct to the best of my knowledge. I
understand that under South Carolina law, providing false information is grounds for denial,
suspension, or revocation of a license, certificate, registration or permit.
Signature of Affiant
SWORN to before me this day of , 20
Notary Signature
Print Name
Notary Public for
My Commission Expires:
Check only one box:
1. I am a United States citizen; or
2.
I am a Legal Permanent Resident of the United States eighteen years of age or older; or
3.
I am a Qualified Alien or non-immigrant under the Federal Immigration and Nationality Act, Public Law
82-414, eighteen years of age or older, and lawfully present in the United States.
4.
Other:
Please submit any documentation that supports this status.
Date of Birth: _
Alien Number: _
I-94 Number:
(If you checked number 2, 3, or 4 you must attach a copy of your immigration documents. See
instruction sheet for a list of accepted immigration documents.)
Rev: 02-02-2015
INSTRUCTION SHEET FOR COMPLETING AFFIDAVIT OF ELIGIBILITY
CHECK box 1:
If you are a United States Citizen by birth or naturalization
CHECK box 2:
If you are a Legal Permanent Resident and you are not a U.S. Citizen, but are residing in the U.S. under legally
recognized and lawfully recorded permanent residence as an immigrant.
PROVIDE A COPY OF ALL IMMIGRATION DOCUMENTS.
CHECK box 3:
If you are a Qualified Alien. You are a Qualified Alien if you are:
An alien who is lawfully admitted for residence under the INA.
An alien who is granted asylum under Section 208 of the INA.
A refugee who is admitted to the United States under Section 207 of the INA.
An alien who is paroled into the United States under Section 212(d)(5) of the INA for a period of at least 1 year.
An alien whose deportation is being withheld under Section 243(h) of the INA (as in effect prior to April 1, 1997)
or whose removal has been withheld under Section 241(b)(3).
An alien who is granted conditional entry pursuant to Section 203(a)(7) of the INA as in effect prior to April 1,
1980.
An alien who is a Cuban/Haitian Entrant as defined by Section 501(e) of the Refugee Education Assistance Act
of 1980.
An alien who has been battered or subjected to extreme cruelty, or whose child or parent has been battered or
subject to extreme cruelty.
PROVIDE A COPY OF ALL IMMIGRATION DOCUMENTS.
ACCEPTED IMMIGRATION DOCUMENTS:
Unexpired Reentry Permit (I-327)
Permanent Resident Card or Alien Registration Receipt Card With Photograph (I-551)
Unexpired Refugee Travel Document (I-571)
Unexpired Employment Authorization Card Which Contains a Photograph (I-766)
Machine Readable Immigrant Visa (with Temporary I-551 Language)
Temporary I-551 Stamp (on passport or I-94)
I-94 (Arrival/Departure Record) in Unexpired Foreign Passport
I-20 (Certificate of Eligibility for Nonimmigrant, F-1, Student Status)
DS2019 (Certificate of Eligibility for Exchange Visitor, J-1, Status)
19
Name (last, first, middle initial): _______________________________________________________
The practicum/internship must have served as part of the degree program. A minimum of a 100-hour counseling practicum
is required. In chronological order, document the dates, hours, location and supervision information for each qualifying
practicum/internship experience.
INSTITUTION/PLACE OF EMPLOYMENT
ADDRESS
DIRECTOR OF PROGRAM
MAJOR SUPERVISOR
DID THE PRACTICUM/INTERNSHIP DEAL DIRECTLY WITH THE ASSESSMENT AND TREATMENT OF SERIOUS PROBLEMS?
YES NO (See Regulations 36.01 (13) and 36.04.1)
TOTAL HOURS
MONTH
FROM
YEAR
MONTH
TO
YEAR
INSTITUTION/PLACE OF EMPLOYMENT
ADDRESS
DIRECTOR OF PROGRAM
MAJOR SUPERVISOR
DID THE PRACTICUM/INTERNSHIP DEAL DIRECTLY WITH THE ASSESSMENT AND TREATMENT OF SERIOUS PROBLEMS?
YES NO (See Regulations 36.01 (13) and 36.04.1)
TOTAL HOURS
MONTH
FROM
YEAR
MONTH
TO
YEAR
INSTITUTION/PLACE OF EMPLOYMENT
ADDRESS
DIRECTOR OF PROGRAM
MAJOR SUPERVISOR
DID THE PRACTICUM/INTERNSHIP DEAL DIRECTLY WITH THE ASSESSMENT AND TREATMENT OF SERIOUS PROBLEMS?
YES NO (See Regulations 36.01 (13) and 36.04.1)
TOTAL HOURS
MONTH
FROM
YEAR
MONTH
TO
YEAR
Total number of hours of counseling experience provided by practica/internships:
South Carolina LPC Review
Practicum/Internship Verication
20
1. Please print or type.
2. Include an official sealed transcript from all graduate institutions attended (do not include undergraduate) or
have transcripts sent directly from the school to CCE.
3. Coursework descriptions for the 9 core requirements and practicum/internship must be submitted. Coursework
descriptions must be photocopied from the catalogue for the year in which the courses were taken.
4. This form must be filled out in order for CCE to review your coursework. If CCE determines that a course does
not fit in a particular category, it will review your transcript for other course possibilities.
Required Courses
(Please refer to pages 10-12 for detailed descriptions)
EACH COURSE CAN ONLY BE USED TO FULFILL ONE REQUIREMENT
1. Human Growth and Development
Studies that provide an understanding of the nature and
needs of individuals at all developmental levels, normal
and abnormal human behavior, personality theory, and
learning theory (all) within cultural contexts.
2. Social and Cultural Foundations
Studies that provide an understanding of societal
changes and trends, human roles, societal subgroups,
societal mores and interaction patterns, and
differing lifestyles.
3. The Helping Relationship
Studies that provide an understanding of philosophic
bases of helping processes, counseling theories and
their applications, helping skills, consultation theories
and applications, helper self-understanding and self-
development, and facilitation of client or
consultee change.
4. Group Dynamics, Processing and Counseling
Studies that provide an understanding of group
development, dynamics and counseling theories; group
leadership styles; group counseling methods and skills;
and other group approaches.
5. Lifestyle and Career Development
Studies that provide an understanding of career
development theories; occupational and educational
information sources and systems; career and leisure
counseling, guidance and education; lifestyle and career
decision-making; and career development program
planning, resources and evaluation.
6. Appraisal
Studies that provide an understanding of group and
individual educational and psychometric theories and
approaches to appraisal data and information gathering
methods, validity and reliability; psychometric statistics;
factors inuencing appraisals; and use of appraisal
results in helping processes.
COURSEWORK CATEGORIES
COURSE TITLE
COURSE
NUMBER
CREDIT
HOURS
INSTITUTION WHERE
COURSE WAS TAKEN
South Carolina LPC Review
Coursework Requirements Verication
21
COURSEWORK CATEGORIES
COURSE TITLE
COURSE
NUMBER
CREDIT
HOURS
INSTITUTION WHERE
COURSE WAS TAKEN
7. Research and Evaluation
Studies that provide an understanding of types of research,
basic statistics, research report development, research
implementation, program evaluation, needs assessment,
and ethical and legal considerations.
8.
Professional Orientation
Studies that provide an understanding of professional
roles and functions, professional goals and objectives,
professional organizations and associations, professional
history and trends, ethical and legal standards, professional
preparation standards, and professional credentialing.
9. Psychopathology
Studies that provide an understanding of morbidity or
pathology of the psyche or mind.
These courses focus
on psychopathology, abnormal psychology, abnormal
behavior, etiology dynamics and treatment of
abnormal behavior. OR
9a. Diagnostics of Psychopathology
Studies that provide an understanding of the diagnostics of
psychopathology as detailed in the current Diagnostic and
Statistical Manual of Mental Disorders.
I, (full name, printed) ______________________________ am the person described and identied, of good moral
character, and the person named in all documents presented in support of this application. I have carefully read the
questions in the foregoing application and have answered them completely, without reservations of any kind, and I declare
that all statements made by me herein are true and correct. Should I furnish any false or incomplete information in this
application, I hereby agree that such act shall constitute the cause for denial or revocation of my license to practice
professional counseling in South Carolina.
Applicant’s Signature: _________________________________________ Date: ______________________
AFFIDAVIT
Cannot be accepted if not signed in the presence of a notary.
State of: _________________________ City/County of: ________________________________________
Sworn to and subscribed before me this ________ day of __________________________, 20___________
Signature of notary public: ________________________________________________________________
My commission expires on: _______________________________________________________________
Afx notary seal or stamp below.
22
REQUIRED BY APPLICANTS FOR LPC/A
a
1. Please print or type.
2. This form must be signed by the licensed professional counselor supervisor (supervisor candidate, if applicable)
and the applicant. Please refer to www.llr.state.sc.us/pol/counselors for a current list of licensed professional
counselor supervisors.
3. It is the applicant’s responsibility to return this form to CCE. LPC associate applications are considered incomplete
without this form.
4. If you have already been been approved for licensure or issued a license in South Carolina, send this form and
all documentation to South Carolina Board of Professional Counselors, P.O. Box 11329, Columbia, SC
29211-1329.
Applicant Name (last, rst, middle initial): _______________________________________________
Social Security Number: ________________________
I have applied for licensure by the South Carolina Board of Examiners for Licensure of Professional Counselors,
Marriage and Family Therapists, Addiction Counselors and Psycho-Educational Specialities and I am required to make
arrangements for board-approved supervision of my counseling practice in order to become board eligible.
Applicant’s Signature
Date
Check appropriate category: □ Supervisor □ Supervisor Candidate
Name (last, rst, middle initial): _________________________________________________________________________________
Preferred mailing address: _____________________________________________________________________________________
____________________________________________________________________________________________________________
City: _____________________________________ State: __________________ ZIP code (+4): __________________________
Daytime telephone number: ____________________________________________________________________________________
LPC/S name: ________________________________________________________________________________________________
(if supervision is to be completed by a supervisor candidate, indicate the candidate’s supervisor)
LPC/S license number: _____________________________ LPC/S license expiration date: _____________________________
Licensed Supervisor or Supervisor Candidate Verication Information
Continued on next page
South Carolina LPC Review
Plan and Arrangements for Clinical
Supervision of Post-Master’s Clinical
Experience in Counseling
23
As per Regulation 36-05(3), applicants for full licensure must submit evidence of a minimum 1,500 hours of supervised
clinical experience in the practice of professional counseling performed over a period of not less than two years under the
supervision of a licensed professional counselor supervisor, supervisor candidate or other qualied mental health practitioner,
as approved by the board. The experience must include a minimum 1,500 hours of supervised clinical experience in the practice
of professional counseling with individuals, couples, families, or groups of which a minimum of 120 hours must be spent in
supervision with a licensed professional counselor supervisor or supervisor candidate (100 hours of individual supervision and
50 hours of either group or individual supervision). For more information about supervisory requirements, contact the South
Carolina Board at 803-896-4658.
Provide details of your plan to complete the required supervised experience. The dates must reflect a two-year
period beginning no earlier than you anticipate being licensed as an LPC associate. Incomplete plans will delay your
application process. If you have questions regarding the completion of this form, contact CCE, or refer to page 3.
Continued on next page
1. Plan for supervised clinical experience of direct counseling client contact:
(Must reflect a minimum of 1,380 hours of supervised clinical experience)
Total
Hours
From
month/year
To
month/year
Plan for 1,380 hours of direct client contact in
counseling of individuals, couples or groups
under the supervision of a licensed professional
counselor supervisor, professional counselor
supervisor candidate, or other quali
ed licensed
mental health practitioner
2. Plan for required 120 hours of post-master’s immediate supervision by a licensed professional
counselor supervisor or supervisor candidate:
Total
Hours
From
month/year
To
month/year
A. Individual (a minimum of 100 hours
required to be individual supervision)
B. Group
Total hours of supervision by a licensed professional
counselor supervisor or supervisor candidate.
Facility name, address, telephone
and type of work experience
(planned over two years)
Position title
From
month/year
To
month/year
click to sign
signature
click to edit
click to sign
signature
click to edit
24
If you plan to be supervised by a supervisor candidate, you must have the supervisor of the LPC supervisor candidate sign
this form also.
Signature of Supervisor:____________________________________________________ Date: __________________
(Original signature required)
Signature of Supervisor Candidate (if applicable):_________________________________ Date: __________________
(Original signature required)
The supervisor does not have to be located on site.
SUPERVISION
Regulation 36-01(1) denes supervision as:
Supervision means face-to-face contact between a supervisor and an intern or other person requiring supervision under
this chapter during which time the person supervised apprises the supervisor of the diagnosis and treatment of each client,
during the supervisory process. The supervisor provides the supervised person with oversight and guidance in diagnosing,
treating, and dealing with clients, and the supervisor evaluates the supervised person’s performance.
The focus of a supervision session is on raw data from clinical work which is made directly available to the supervisor
through such means as written clinical materials, direct (live) observation, co-therapy, audio and video recordings, and
live supervision.
Supervision is a process clearly distinguishable from personal psychotherapy and is contrasted in order to serve
professional goals.
25
INSTRUCTIONS
Applicants for licensure on the basis of endorsement from another state must complete the log on the following page. It
should be included with the application and other required documentation that is outlined in the application packet. You
must maintain an active and current license in your home state while applying for licensure on the basis of endorsement
from another state.
• South Carolina requires evidence of a minimum of 1,500 hours of supervised clinical experience in
counseling performed over a period of not less than two years under the supervision of a licensed
psychologist, psychiatrist or a professional counselor supervisor (LPC/S).
• This experience must include direct client contact with individuals, couples, families or groups, of which
a minimum of 120 hours should have been in immediate supervision with the LPC/S.
•
The 120 hours of supervision should include a minimum of 100 hours in individual supervision and 50 hours
can be either individual or group supervision with the LPC/S.
• Verification of both 1,380 hours of supervised clinical experience and 120 hours of immediate supervision
must be submitted by completing a Confirmation of Post-Master’s Clinical Supervision form signed by each
supervisor that was used OR contacting your current state’s licensing board office to furnish proof of your
supervised experience.
• In addition to providing the above verification, every endorsement applicant must complete the Log for
Clinical Supervision of Post-Master’s Clinical Experience in Counseling.
• By completing the log, you should be able to determine if you meet the requirements for licensure as a
professional counselor in South Carolina.
• The South Carolina board office will review your documentation after CCE has tentatively approved your
education and you have passed the required examination. Upon official review by the South Carolina board
office, you will be notified of any deficiencies, if any, related to the experience and supervised hours. If you
have not provided verification of 1,380 hours of supervised clinical experience and 120 hours of immediate
supervision, as defined above, you will be licensed as an LPC intern for the time that it takes to complete the
requirements.
REQUIRED FOR APPLICANTS APPLYING FOR LICENSURE BY ENDORSEMENT
South Carolina LPC Review
Log for Clinical Supervision of
Post-Master’s Clinical Experience
Continued on next page
26
LOG FOR CLINICAL SUPERVISION OF POST-MASTER’S CLINICAL EXPERIENCE
Name of Applicant: ________________________________________________________________________
Currently licensed in the state(s) of:____________________________________________________________
Current License Type:
□ Professional Counselor/Mental Health Counselor
□ Marriage and Family Therapist
□ Other:____________________________________
Dates
(From/To)
Name of Supervisor
Type of License Held
By Supervisor
Group
Supervision
Hours
Hours of Direct
Client Contac
t
Individual
Supervision Hours
(at least 100 required)
Total hours of direct client contact: _____________
Total hours of individual supervision: _____________
Total hours of group supervision: _____________
In order to meet South Carolina licensing requirements, the above totals must reflect a minimum of 1,38
0 direct client
contact hours and 120 hours of supervision. At least 100 of the supervision hours must be individual, and the remaining 20
can be individual or group.
27
REQUIRED (see items 3 and 4 below)
1. Please print or type.
2. This form must be signed by the licensed supervisor (or supervisor candidate, if applicable) and the applicant.
3. Applicants who are required to be interns should return this completed form after the completion of the two-year intern
licensure period. Mail to: SC Board of Professional Counselors, P.O. Box 11329, Columbia, SC 29211-1329.
4. Applicants by endorsement should return this form to CCE with their other application materials.
Applicant name (last, rst, middle initial): _______________________________________________
Social Security number: ________________________
I have applied for licensure by the South Carolina Board of Examiners for Licensure of Professional Counselors, Marriage and
Family Therapists, Addiction Counselors, and Psycho-Educational Specialists. I am required to provide documentation of a
minimum of 150 hours of supervision with a licensed professional counselor supervisor or supervisor candidate of which a minimum
of 100 hours are required to be individual supervision and 2
0 of these hours can be either group or individual supervision. Please
complete the information below and return the form to me.
Applicant’s signature
Date
Check appropriate category: □ Supervisor □ Supervisor candidate
Name (last, rst, middle initial): _______________________________________________________________________
Preferred mailing address: ___________________________________________________________________________
__________________________________________________________________________________________________
City: ________________________________ State: _____________ ZIP code (+4): ___________________________
Daytime telephone number: __________________________________________________________________________
LPC/S name: ______________________________________________________________________________________
(If supervision was completed by a supervisor candidate, indicate the candidate’s supervisor.)
LPC/S license number: _____________________________ LPC/S license expiration date: ____________________
Licensed Supervisor or Supervisor Candidate Verication Information
Continued on next page
INFORMATION BELOW TO BE COMPLETED BY SUPERVISOR (not applicant)
□ I verify that the applicant was under my supervision, at which time I critiqued the applicant’s counseling and
counseling-related skills based on one or more of the following forms of observation of the supervisee’s counseling
practice (check all that apply):
□ Direct/live observation □ Live supervision □ Audio recordings
□ Written clinical materials □ Video recordings □ Co-therapy
South Carolina LPC Review
Confirmation of Clinical Supervision of
Post-master’s Client Contact in Counseling
28
Name, address, telephone
and type of work experience
(Minimum of two years experience)
Applicant’s Employment
RECOMMENDATION
□ I recommend / □ I do not recommend this applicant for licensure as a south carolina licensed professional
counselor. Note: If you do not recommend this applicant/intern, the board requests that you send a separate letter directly
to the board ofce stating your reasons.
Additional Comments:
Afdavit:
I attest that all information provided herein concerning supervision and work experience is accurate to the best of my
knowledge and is in keeping with the Professional Counselors, Marriage and Family Therapists, Addiction Counselors,
and Psycho-Educational Specialist Practice Act. I understand that supervision for licensed associates and the duration
for associate licensure are for a period of not less than two years.
Signature of supervisor: ___________________________________________________ Date:_____________
(Original signature required)
Signature of supervisor candidate (if applicable): ________________________________ Date:____________
(Original signature required)
Total Years
From
month/year
To
month/year
1. Conrmation of Supervised Clinical Experience of Direct Counseling Client Contact
(must reflect a minimum of 1,38
0 hours of supervised clinical experience)
Confirmation of 1,380 hours of direct client contact
in counseling of individuals, couples, or groups under
the supervision of a licensed professional counselor
supervisor, supervisor candidate, or other qualied
licensed mental health practitioner
Total
Hours
From
month/year
To
month/year
2. Confirmation of 120 hours of Post-Master’s Immediate Supervision
Conrmation of hours of supervision by a licensed
professional counselor supervisor or supervisor
candidate (attach the supervision log)
A. Individual (a minimum of 100 hours
required to be individual supervision)
B. Group
Total
Hours
From
month/year
To
month/year
29
REQUIRED FOR THOSE APPLYING FOR LICENSURE BY ENDORSEMENT
Part 1- To be completed by the South Carolina applicant.
Applicant name
(last, rst, middle initial): ___________________________________________________________________
Social Security number: _______________ Applicant’s license number: _____________ Type of license: ___________
I hereby authorize the release of licensure information to the Center for Credentialing & Education and the South
Carolina Board of Examiners Licensure of Professional Counselors, Marriage and Family Therapists, Addiction
Counselors, and Psycho-Educational Specialists.
Applicant’s Signature
Date
PART II – To be completed by the state board where the South Carolina applicant is currently licensed.
Board: Please send this form directly to CCE at the address below when completed.
Title of license: ____________________________________________________________________________________
Date of initial license (mm/dd/yyyy): __________________ Expiration date of license (mm/dd/yyyy): ____________________
Form completed by (please print):
Name and title: ________________________________________________________________
Signature: ____________________________________________________________________
Board address and telephone number _______________________________________________
_____________________________________________________________________________________
Send completed
form directly to:
SC Board of
Examiners
C/O CCE
3 Terrace Way
Greensboro, NC
27403-3660
South Carolina LPC Review
Verication of Licensure for Endorsement
Is this license current and in good standing?
If not, please explain on the back of this form.
Was this license issued through a grandfathering clause?
Did the licensee take and pass a written examination?
If yes, score achieved: ________________________
Name of exam taken: _________________________
Date exam passed: __________________________
Is there any record of disciplinary action taken against this licensee?
If yes, please explain on the back of this form.
Do you require verication of continuing education for licensure renewal?
Number of years in licensure period: _____________
Number of hours per licensure period: ____________
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
30
Application and Education Review Fee: $170
Please check the application option:
□ Licensed Professional Counselor (LPC)
□ Licensed Professional Counselor Associate (LPC/A)
On the basis of:
□ Examination, education, clinical experience and supervision
□ Endorsement from another state
PLEASE NOTE: CCE accepts complete applications to assure all required forms are complete and reviews the
educational experience of applicants for the South Carolina licensing board. All other aspects of the review
process are handled by the South Carolina licensing board.
South Carolina LPC Review
Payment Voucher
METHOD OF PAYMENT
Telephone: DAY:
EVENING:
Applicant’s Name:
□ Enclosed is a check or money order payable to CCE in the amount of $170.
□ Please charge the credit card listed below in the amount of $170.
Cardholder Signature: ______________________________________ Date
(mm/dd/yyyy): ____________
Account
Number:
Card Security Code (from back of card):
Name on Card:
Card Type:
VISA
MasterCard
American Express
Expiration
Date:
SUBMIT YOUR APPLICATION AND PAYMENT
• Mail: CCE; P.O. Box 63223; Charlotte, NC 28263-3223 •
Fax: 336-482-2852
Submit completed application
and payment:
Mail: CCE
P.O. Box 63223
Charlotte, NC 28263-3223
Fax: 336-482-2852
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

South Carolina Application and Education Review (Center for Credentialing & Education)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 26 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document