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Virginia Board of Counseling
Applications and Instructions

 

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Qualified Mental Health Professional (QMHP) and Registered Peer Recovery Specialists (RPRS)

QMHP – Adult

Please click here to review the Application Handbook.

Click here to begin the QMHP-A Grandfathered Application: This application type is for individuals who were employed as a QMHP-A in Virginia prior to December 31, 2017 and met the qualifications for QMHP-A during the time of employment as defined by DBHDS.

Click here to begin the QMHP-A Initial Application: This application type is for individuals who do not meet the grandfather requirements but have completed the required education and supervised experience with adults with mental illness as defined in the Regulations.

QMHP – Child

Please click here to review the Application Handbook.

Click here to begin the QMHP-C Grandfathered Application: This application type is for individuals who were employed as a QMHP-C in Virginia prior to December 31, 2017 and met the qualifications for QMHP-C during the time of employment as defined by DBHDS.

Click here to begin the QMHP-C Initial Application: This application type is for individuals who do not meet the grandfather requirements but have completed the required education and supervised experience with children and adolescents with mental illness as defined in the Regulations.

Qualified Mental Health Professional Trainee

Please click here to review the Application Handbook.

Click here to begin the QMHP- Trainee Initial Application: This application type is for individuals who are starting or are currently accruing supervised experience towards QMHP-A and/or QMHP-C. (Comparable to the DBHDS and DMAS designation QMHP-Eligible or QMHP-E)

Registered Peer Recovery Specialists

Please click here to review the Application Handbook.

Click here to begin the RPRS Initial Application: This application type is for individuals who hold a CPRS certificate from VCB, NCPRSS from NAADAC, current and valid Peer Recovery Specialist certification from another state that was accepted by DBHDS or certified by the Veterans Administration as a Peer Recovery Specialist and has completed the DBHDS Peer Recovery Specialist Training.

Additional QMHP Forms

(The below forms are to supplement the online application and do not include the instructions. All forms and instructions are to be printed during the online application process. Forms should be mailed to the Board after you complete and submit the online application and fee. Forms without the online application will not be reviewed or considered. Original signatures are required.)

QMHP-A Attestation of Prior Experience (Supplemental documentation for QMHP-A Grandfather Application)

QMHP-C Attestation of Prior Experience (Supplemental documentation for QMHP-C Grandfather Application)

QMHP-A Verification of Supervised Experience (Supplemental documentation for QMHP-A Application)

QMHP-C Verification of Supervised Experience (Supplemental documentation for QMHP-C Application)

Verification of Internship/Practicum for QMHP (Supplemental documentation for QMHP-A and QMHP-C Application)

 

Certified Substance Abuse Counselors

CSAC applications/forms have been updated recently. After August 1, 2018, the Board will only accept new versions of forms and applications. Forms that were previously signed by the supervisor or by a school official can still be considered past the 8/1/2018 date.

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

 

Certified Substance Abuse Counselor Assistants

CSAC-A applications/forms have been updated recently. After August 1, 2018, the Board will only accept new versions of forms and applications. Forms that were previously signed by the supervisor or by a school official can still be considered past the 8/1/2018 date.

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

 

Licensed Professional Counselors

LPC applications/forms have been updated recently. After August 1, 2018, the Board will only accept new versions of forms and applications. Forms that were previously signed by the supervisor or by a school official can still be considered past the 8/1/2018 date.

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, Degree and Internship Form for LPC Licensure (PDF file)

Verification of Internship Form (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)

 

 

Supervisor Approval Applications

Supervisor Approval Application for LPC, LMFT and LSATP (PDF file)

Supervisor Approval Application for CSAC and CSAC-A (PDF file)

 

Licensed Substance Abuse Treatment Practitioners

LSATP applications/forms have been updated recently. After August 1, 2018, the Board will only accept new versions of forms and applications. Forms that were previously signed by the supervisor or by a school official can still be considered past the 8/1/2018 date.

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 Treatment 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)

Verification of Post-Licensure Active Practice Form (PDF file)

 

Certified Rehabilitation Providers

CRP applications/forms have been updated recently. After August 1, 2018, the Board will only accept new versions of forms and applications. Forms that were previously signed by the supervisor or by a school official can still be considered past the 8/1/2018 date.

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 (PDF file)

Verification of Experience for Rehabilitation Provider Certification (PDF file)

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

Supervisor Out-of-State Licensure or Certification Form (PDF file)

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

Rehabilitation Provider Application for Reinstatement of a Lapsed Certificate (PDF file)

 

Marriage and Family Therapists

LMFT applications/forms have been updated recently. After August 1, 2018, the Board will only accept new versions of forms and applications. Forms that were previously signed by the supervisor or by a school official can still be considered past the 8/1/2018 date.

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)

Verification of 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)

 

 

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

Initial Contact Form

Approval Request Forms

CE and Education Approval Request

Evaluator Approval Request

Compliance Supervisor Request

Therapist Approval Request

Reports

Employer Notification Form

Group Attendance Report

Physician Prescription Report

Self-Report

Supervisor Report

Therapy Report (Initial)

Therapy Report (Quarterly)