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Virginia Board of Counseling
Applications and Instructions

 

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Board of Counseling applications and forms were recently updated. Effective March 1, 2017, the Board will no longer accept outdated applications. (Outdated Quarterly Evaluations and Verification of Clinical Supervision forms that were previously signed by a supervisor can still be considered. Additionally, outdated Verification of Education and Internship forms that were previously signed by a school official can still be considered.)

Certified Substance Abuse Counselors

CSAC and CSAC-A Certification Process Handbook (PDF file)

Application Packet for CSAC Supervision (Initial and Add/Change) (PDF file)

Application Packet for CSAC by Examination (PDF file)

Application Packet for CSAC by Endorsement (PDF file)

Reinstatement Application for Certified Substance Abuse Counselors (PDF file)

Substance Abuse Counselor or Counseling Assistant Application for Reinstatement of Certificate Following Revocation or Suspension (PDF file)

Additional CSAC Forms

Verification of Clinical Supervision Form for CSAC Certification

Didactic Training Verification Form for CSAC Certification

Request for Termination of Supervision Form

Request for Verification of VA License or Certification Form

Out of State License or Certification Verification Form

Supervisor Out of State License or Certification Verification Form

Request for Name and Address Change Form (pdf)

 

Certified Substance Abuse Counselor Assistants

CSAC and CSAC-A Certification Process Handbook (PDF file)

Application packet for Certified Substance Abuse Counselor Assistant (PDF file)

Reinstatement Application for Certified Substance Abuse Counselor Assistant (PDF file)

Substance Abuse Counselor or Counseling Assistant Application for Reinstatement of Certificate Following Revocation or Suspension (PDF file)

Additional CSAC-A Forms

Verification of Experience Form for CSAC-A Certification

Didactic Training Verification Form for CSAC-A Certification

Request for Verification of VA License or Certification Form

Request for Name and Address Change Form (pdf)  

 

Licensed Professional Counselors

LPC Licensure Process Handbook (PDF file)

Application Packet for Initial Supervised Residency for LPC Licensure (PDF file)

Application Packet to Add/Change to Supervision for LPC Licensure (PDF file)

Application Packet for LPC by Examination (PDF file)

Application Packet for LPC by Endorsement (PDF file)

Reinstatement Application Packet for Licensed Professional Counselors (PDF file)

Application Packet for Reinstatement of a Revoked or Suspended License (PDF file)


Additional LPC Forms

Verification of Coursework and Internship Form for LPC Licensure (PDF file)

Supervisor Out of State License or Certification Verification Form (PDF file)

Verification of Clinical Supervision Form for LPC Licensure (PDF file)

Quarterly Evaluation Form for LPC Licensure (PDF file)

Supervision Summary Form for LPC Licensure

Request for Termination of Supervision Form (PDF file)

Out of State License or Certification Verification Form (PDF file)

Verification of Clinical Practice for 24 of the Last 60 Months for LPC Licensure (PDF file)

Request for Verification of VA License or Certification Form (PDF file)

Request for Name and Address Change Form (pdf)  

 

 

Supervisor Approval Applications

Supervisor Approval Application for LPC, LMFT and LSATP

Supervisor Approval Application for CSAC and CSAC-A

 

Licensed Substance Abuse Treatment Practitioners

Application Packet for Initial Supervised Residency for LSATP Licensure (PDF file)

Application Packet to Add/Change to Supervision for LSATP Licensure (PDF file)

Application Packet for Licensed Substance Abuse Treatment Practitioner by Examination (PDF file)

Application Packet for Licensed Substance Abuse Treatment Practitioner by Endorsement (PDF file)

Reinstatement Application for Licensed Substance Abuse Treatement Practitioners (PDF file)

Application Packet for Reinstatement of a Revoked or Suspended License (PDF file)

Additional LSATP Forms

Quarterly Evaluation Form for LSATP Licensure (PDF file)

Supervision Summary Form for LSATP Licensure (PDF file)

Verification of Clinical Supervision Form for LSATP Licensure (PDF file)

Verification of Required Coursework and Internship Form for LSATP Licensure (PDF file)

Supervisor Out of State License or Certification Verification Form (PDF file)

Out of State License or Certification Verification Form (PDF file)

Request for Termination of Supervision Form (PDF file)

Request for Verification of VA License or Certification Form (PDF file)

Request for Name and Address Change Form (pdf)

 

Certified Rehabilitation Providers

General Information for Certification as a Rehabilitation Provider (Word .doc)

Memo regarding Applications (Word .doc)

Frequently Asked Questions (Word .doc)

Application for Certification as a Rehabilitation Provider (Word .doc)

Verification of Experience for Rehabilitation Provider Certification (Word .doc)

Verification of Licensure/Certification (PDF file)

Licensure/Certification Verification of Out-of-State Supervisor (Word .doc)

Rehabilitation Provider Application for Reinstatement of a Lapsed Certificate (Word .doc)

 

Marriage and Family Therapists

LMFT Licensure Process Handbook (PDF file)

Application Packet for Initial Supervised Residency for LMFT Licensure (PDF file)

Application Packet to Add/Change to Supervision for LMFT Licensure (PDF file)

Application Packet for LMFT by Examination (PDF file)

Application Packet for LMFT by Endorsement (PDF file)

Reinstatement Application for Marriage and Family Therapist (PDF file)

Application Packet for Reinstatement of a Revoked or Suspended License (PDF file)

Additional LMFT Forms

Verification of Clinical Supervision Form for LMFT Licensure (PDF file)

Quarterly Evaluation Form for LMFT Licensure (PDF file)

Verification of Clinical Practice for 24 of the Last 60 Months for LMFT Licensure (PDF file)

Supervision Summary Form for LMFT Licensure (PDF file)

Verification of Coursework and Internship Form for LMFT Licensure (PDF file)

Supervisor Out of State License or Certification Verification Form (PDF file)

Out of State License or Certification Verification Form (PDF file)

Request for Termination of Supervision Form (PDF file)

Request for Verification of VA License or Certification Form (PDF file)

Request for Name and Address Change Form (pdf)

 

 

Continuing Education Forms

Continuing Education Summary Form - LPC (Word .doc)

Continuing Education Summary Form - LMFT (Word .doc)

Continuing Education Summary Form - LSATP (Word .doc)

Formal Staffing Attendance Form (Word .doc)

Form for Reporting Counseling Independent Study (Word .doc)

 

Compliance Forms & Information

Compliance FAQs (Word .doc)

Self Report Form

Licensed Professional Counselor (Word .doc)

Performance Evaluation Form

Supervisor Report Form – Behavioral Sciences (Word .doc)

Chaperone Report Form (Word .doc)

Miscellaneous Compliance Forms

Chaperone Fact Sheet (Word .doc)

Drug Log for Prescribers (.xls)

Employer Notified of Board Order (Word .doc)

Initial Contact Form (Word .doc)

Prescriber Report to Board of Drugs or Prescription Given to Licensee (Word .doc)

Recovery Support Group Attendance Log (Word .doc)

Approval Forms

Chaperone Approval Request Form (Word .doc)

Evaluator Approval Request (Word .doc)

Supervisor Approval Request – Behavioral Sciences (Word .doc)

Therapist Approval Request (Word .doc)