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STATEMENT OF PROFESSIONAL INTENT

Users are to fill out the form and provide a valid email address. Once submitted a filled out copy will be sent to the user's email address, users are to print, date, and sign each page of the form and then submit it to the Board for review. When printing the form be sure that the settings for header/footer information are set to blank.

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Email (required):

Licensed Associate Counselor (LAC)

Licensed Professional Counselor (LPC)

Licensed Associate Marriage /Family Therapist (LAMFT)

Licensed Marriage and Family Therapist (LMFT)


Name (Required):

Date (Required):

NATURE OF MY COUNSELING/PSYCHOTHERAPY PRACTICE (AND/OR) MARRIAGE & FAMILY THERAPY PRACTICE

DISORDERS, ISSUES, PRESENTING PROBLEMS I ACCEPT

THEORETICAL APPROACHES I USE

METHODS AND TECHNIQUES I USE

POPULATION(S) I SERVE

ASSESSMENT INSTRUMENTS I ADMINISTER AND PURPOSE FOR USE

Projective Techniques are not permitted under this license. [Act 593 of 1979, Sec. 3(e) 2]

 



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