Verification of Graduate Counseling Experience
[To be completed by University Faculty for LCMHCA/LCMHC Applicants]
Indicate to which Applicant this verification form applies:
Name: _______________________________________________
VERIFICATION OF GRADUATE COUNSELING EXPERIENCE INSTRUCTIONS
1. PRINT or TYPE using BLACK Ink to complete this verification of graduate counseling experience. Person verifying graduate counseling
experience must be a university faculty member as defined in Rule .0206.
2. ALL SECTIONS must be completed or the verification of graduate counseling experience will be returned.
3. The verification of graduate counseling experience should be enclosed in a sealed envelope and signed across the flap. Mail the signed and
sealed envelope to the NCBLCMHC Board Office at: NCBLCMHC, PO Box 77819, Greensboro, NC 27417
I. GENERAL INFORMATION - To be completed by person verifying graduate counseling experience.
Name (Last, First, Middle):
Title:
University: Department or Program Name:
Mailing Address (Street and/or Box Number, City, State, Zip Code):
Business Phone:
Email Address:
II. VERIFICATION OF GRADUATE COUNSELING EXPERIENCE - To be completed by person verifying graduate counseling
experience.
Name of Agency where Graduate Counseling Experience Occurred:
Address (Street and/or Box Number, City, State, Zip Code): Business Phone:
Were you the University Supervisor for the graduate counseling experience? Yes No If not, explain how
you have verified the graduate counseling experience:
Total hours of Individual clinical supervision received during graduate counseling experience:
Total hours of Group clinical supervision received during graduate counseling experience:
Total Hours of Direct Client
Contact
Total Hours of Indirect
Client Contact
Practicum
Internship
Practicum
Internship
Practicum
Internship
Practicum
Internship
Percentage (Board use only)
I verify that the statements in this verification of professional counseling experience are true and correct to the best of m
y
Signature of Person Verifying: ____________________________________________ Date: __
______________
This version supersedes all previous versions Revised 02/05/2020
