Fillable (This Form Should Not Be Used For License (Michigan)

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(This Form Should Not Be Used For License (Michigan)

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Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 335-0918
www.michigan.gov/bpl
BPLHelp@michigan.gov
APPLICATION FOR A PROFESSIONAL COUNSELOR LICENSE
Authority: 1978 PA 368
(This Form Should Not Be Used For License Renewal)
Applicant’s Legal
First Name
Legal Middle Name
Legal Last Name
U.S. Social Security # (New Applicants Only)
Date of Birth (New Applicants Only)
10-Digit MI Permanent ID/License Number (If Applicable)
Address
City
State
Zip Code
Country
Telephone Number
List any other name or alias by which you have ever been known, including maiden name, if applicable:
CHECK THE LICENSE/OBTAINED BY METHOD FOR OFFICE USE ONLY
L.P.C – By Endorsement
L.P.C – By Exam
L.P.C. – Relicensure
Limited L.P.C.
Limited L.P.C. Relicensure
$124.30 6401-09
$124.30 6401-01
$144.30 6401-06
$ 86.45 6401-03
$106.45 6401-06
Your check or money order, drawn from a U.S. financial institution
and made payable to the STATE OF MICHIGAN, must accompany
this request. DO NOT SEND CASH. Fees are non-refundable.
License Number
Issue Date
LARA/BPL-COUNSELAPP (1/27/20)
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 5
LARA/BPL-COUNSELAPP (1/27/20)
2 of 5
Professional Education
(Attach additional sheets if necessary)
Name of School Name of Degree Granted
License(s) in Other State(s) and/or Country
List each state or country where you have ever held a professional counselor profession license, the license or registration
number, the date issued, how the license was obtained, and whether sanctions have ever been imposed and/or if
disciplinary proceedings are currently pending against that license or registration. (Attach additional sheets if necessary).
If you indicate there have been sanctions imposed and/or pending disciplinary proceedings against a license or
registration, you must submit documentation that the sanctions are not in force or there are not pending disciplinary
proceedings at the time of this application.
State/Country
Permanent
License/Registration
Number
Date of
Issuance
How Obtained
(Examination,
Endorsement)
Have You Ever Had Sanctions
Imposed Against this
License/Registration OR are
there Pending Disciplinary
Proceedings? (If Yes, be
Specific)
Good Moral Character Questions
If you answer “yes” to either of the next two questions, you must submit a written explanation as to what took place
including date(s) of occurrence(s), court documents, documentation which shows at the current time you have the
ability to, and are likely to, serve the public in a fair, honest, and open manner, that you are rehabilitated, or that the
substance of the former offense is not reasonably related to the occupation or profession for which you are seeking a
license.
Answering “yes” to the following question may not automatically prevent you from obtaining a license. In evaluating
your good moral character, the department will consider whether the substance of your former offense is reasonably
related to the profession to which you are seeking a license. Also, please know that you may request a preliminary
determination from the Department concerning whether any court judgments against you would likely result in a denial
of a license for failing to meet the good moral character requirement. More information about requesting a preliminary
determination can be found at www.michigan.gov/healthlicense.
Have you ever been convicted of a felony? Yes No
Have you ever been convicted of a misdemeanor punishable by imprisonment for a maximum Yes No
term of two years or a misdemeanor involving the illegal delivery, possession, or use of alcohol or
a controlled substance?
LARA/BPL-COUNSELAPP (1/27/20)
3 of 5
Required Additional Documents:
All Applicants
•
Upon review of your application, you will be mailed an Application Confirmation letter containing instructions to
complete the Criminal Background Check (except those applicants seeking relicensure, if the license expired
within the last three years).
Counselor License by Endorsement
Applicants for licensure by endorsement who have been licensed in another state or territory of the United States
and have practiced counseling for a minimum of 5 years at the time of application must submit the following:
•
A Professional Disclosure Statement (See specifications on Page 5).
•
Verification/certification of license to be submitted directly to this office by the licensing agency of any state or territory
of the United States in which you hold a current license or ever held a license as a professional counselor. Verification
includes, but is not limited to, showing proof of any disciplinary action taken or pending disciplinary action imposed.
Applicants for licensure by endorsement who have been licensed in another state or territory of the United States
and have practiced counseling for less than 5 years at the time of application must submit the following:
•
Same requirements as Counselor License by Exam (see below)
Counselor License by Exam
Applicants must submit the following:
•
Official transcripts submitted directly to this office from an accredited college or university confirming receipt of a
master’s or doctoral degree in counseling from a qualified program, or a degree determined by the department
in consultation with the board to be substantially equivalent to a counseling degree from a qualified program.
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. The program must not be less than 48 semester hours or 72 quarter hours in counseling topics.
•
Certification of Counseling Education form submitted to this office directly from your educational institution.
•
A Professional Disclosure Statement (See specifications on Page 5).
•
Verification/certification of license to be submitted directly to this office by the licensing agency of any state or territory
of the United States in which you hold a current license or ever held a license as a professional counselor. Verification
includes, but is not limited to, showing proof of any disciplinary action taken or pending disciplinary action imposed.
•
Certification of your examination scores must be submitted directly to this office from the examination agency. You
may request score reports for the National Counselor Examination (NCE) from the National Board for Certified
Counselors at http://www.nbcc.org/Exams/. You may request score reports for the Commission on Rehabilitation
Counselor Certification (CRCC) Examination from the CRCC at https://www.crccertification.com/. Scores from only
one testing organization is required. You may register for the National Counselor Examination (NCE)
at http://www.cce-global.org or email a request for a paper registration to paperreg@cce-global.org. You may
register for the Commission on Rehabilitation Counselor Certification (CRCC) Examination
at http://crccertification.com/crc-certification.
•
Completed Counseling Work Experience form submitted directly to this office from your supervisor. An applicant
must have completed counseling experience under the supervision of a licensed professional counselor. All
supervised experience obtained in Michigan must be completed after the limited counselor license has been issued.
Supervised experience gained prior to obtaining the limited license cannot be counted toward licensure. Individuals
with a master's degree must accrue 3,000 hours of post-degree counseling experience in not less than a two-year
period with at least 100 hours accrued in the immediate physical presence of the supervisor. Individuals who have
completed a doctoral degree in counseling must accrue 1,500 hours of post degree counseling experience in not
less than a one-year period with at least 50 hours accrued in the immediate physical presence of the supervisor.
LARA/BPL-COUNSELAPP (1/27/20)
4 of 5
Limited License
Applicants must submit the following:
•
Official transcripts submitted directly to this office from an accredited college or university confirming receipt of a
master’s or doctoral degree in counseling from a qualified program, or a degree determined by the department in
consultation with the board to be substantially equivalent to a counseling degree from a qualified program. 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. The program
must not be less than 48 semester hours or 72 quarter hours in counseling topics.
•
Certification of Counseling Education form submitted to this office directly from your educational institution.
•
A Professional Disclosure Statement (See specifications on Page 5).
•
Verification/certification of license to be submitted directly to this office by the licensing agency of any state or territory
of the United States in which you hold a current license or ever held a license as a professional counselor. Verification
includes, but is not limited to, showing proof of any disciplinary action taken or pending disciplinary action imposed.
Applicants for relicensure whose license has lapsed for less than 3 years at the time of application must
submit the following:
•
A Professional Disclos
ure Statement (See specifications on Page 5).
•
Verification/certification
of
license
to be submitted directly to this office by the licensing agency of any state or territory
of the United States in which you hold a current license or ever held a license as a professional counselor. Verification
includes, but is not limited to, showing proof of any disciplinary action taken or pending disciplinary action imposed.
Applicants for relicensure whose license was lapsed for more than 3 years at the time of application must
submit:
•
A Professional Disclosure Statement (See specifications on Page 5).
•
AND one of the following:
o
Takes or retakes and passes 1 of the following:
The National Counselor Examination (NCE) developed by the National Board for
Certified Counselors. You may request score reports for the NCE from the National Board
for Certified Counselors at www.nbcc.org/Exams/ScoreReport.
The certification examination given by the Commission on Rehabilitation Counselor
Certification (CRCC). Certification of your examination scores must be submitted directly to
this office from the examination agency. You may request score reports for the CRCC
Examination from the CRCC at www.crccertification.com/.
o
Submit evidence of current certification issued by the National Board for Certified Counselors,
the Commission on Rehabilitation Counselor Certification, or an equivalent program submitted directly
to this office from the agency. You may request certification from the National Board for Certified
Counselors at www.nbcc.org/Certification or from the CRCC at www.crccertification.com/.
Applicants for relicensure whose license was issued based on grandfathering must submit :
•
A Professional Disclosure Statement (See specifications on Page 5).
•
Verification/certification
of license to
be submitted directly to this office by the licensing agency of any state or territory
of the United States in which you hold a current license or ever held a license as a professional counselor. Verification
includes, but is not limited to, showing proof of any disciplinary action taken or pending disciplinary action imposed.
Relicensure - Limited License or Full License
LARA/BPL-COUNSELAPP (1/27/20)
5 of 5
Professional Disclosure Statement
Section 18113 of the Michigan Public Health Code, 1978 PA 368, as amended, requires that a licensed counselor
furnish a Professional Disclosure Statement to all prospective clients before engaging in counseling services.
A Professional Disclosure Statement is required from every applicant, even if you are not currently practicing. You must
provide a separate Professional Disclosure Statement for each practice location. You are required to submit a new
Professional Disclosure Statement to the board within 30 days if you have any changes to the required information.
Your license cannot be issued without a Professional Disclosure Statement(s) on file. Attach a copy of your
Professional Disclosure Statement(s) to your application for licensure.
YOUR PROFESSIONAL DISCLOSURE STATEMENT MUST INCLUDE ALL OF THE FOLLOWING INFORMATION:
•
Your name, business address, and telephone number. (If not currently employed provide your name, address and
telephone number as shown on your application for licensure.)
•
A description of your practice.
•
A description of your education and experience.
•
The fee you charge your clients or a statement if you do not charge a fee
•
The following information must be included in your Professional Disclosure Statement in the event your client(s)
would like to file a complaint regarding your counseling services. This address and phone number should not be
used for any other purpose.
Michigan Department of Licensing and Regulatory Affairs
Bureau of Professional Licensing
Investigations & Inspections Division
P.O. Box 30670
Lansing, MI 48909
(517) 241-0205
If you are applying for the limited counselor license, you must include the name and license number of the licensed
professional counselor who will be supervising your 3000 hours of post-degree experience.
CERTIFICATION AND SIGNATURE
I understand that it is the policy of this agency to secure a criminal conviction history as part of the pre-licensure screening
process. I authorize this agency to use the information provided in this application to obtain a criminal conviction history
file search from the Federal Bureau of Investigation, Central Records Division of the Michigan Department of State Police,
law enforcement, or judicial record-keeping organization. I consent to the release of information regarding a disciplinary
investigation conducted by a similar licensure, registration, or specialty licensure or specialty certification board of this or
any other state, of the United States military, of the federal government, or of another country.
I certify that the statements in this application are true and complete. I understand that any omitted statement,
misrepresentation, or fraud may be cause for denial of my application, disciplinary action, or may be punishable by law.
I further attest that I have a written policy for protecting, maintaining, and providing access to my medical records in
accordance with Section 16213 of the Public Health Code, 1978 PA 368, MCL 333.16213, and for complying with Section
16213 in the event that I sell or close my practice, retire from practice, or otherwise cease to practice under Article 15 of
the Public Health Code, 1978 PA 368, MCL 333.16101 to 333.18838.
_ _ _ _
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(This Form Should Not Be Used For License (Michigan)

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Completed 9 February 2021

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