2011 Edition
KENTUCKY BOARD OF LICENSED PROFESSIONAL COUNSELORS
PO BOX 1360
FRANKFORT KY 40602
http://lpc.ky.gov
RENEWAL APPLICATION FOR LICENSED PROFESSIONAL CLINICAL COUNSELOR
Your Licensed Professional Clinical Counselor credential expires on October 31, 2011. In accordance with KRS 335.535 and regulations (201 KAR 36:020) governing this profession, you are required to renew your license annually with the transmittal of this form and a renewal fee of $150.00, (check or money order) made payable to the Kentucky State Treasurer. Please return this completed form with the fee to the address above prior to the deadline date of October 31,2011. The fee for renewals received during the 60 day grace period is $25.00. Credentials not renewed prior to December 31,2011 will be terminated and you must immediately CEASE AND DESIST (no exceptions) the use of the title Licensed Professional Clinical Counselor in Kentucky.
If your renewal reminder indicated that you had been selected for AUDIT please send copies of evidence of having completed 10
hours of continuing education as defined in 201 KAR 36:030.
PLEASE COMPLETE ALL OF THE FOLLOWING:
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(Please complete hack page ofrenewalform)
2011 Edition
1. Have you been convicted of a felony since your last application or renewal? “Conviction” including all instances in
which a plea of no contest is the basis of the conviction. |
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)No |
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)Yes |
If yes, list offense and provide details on a separate sheet of paper. |
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2. Have you been subject to disciplinary action by a mental health credentialing board? |
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)No |
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) Yes |
If yes, give details on a separate sheet of paper. |
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3.List any state in which you have become licensed or certified since your last renewal, the type of license or certification, and the number of the certification or license:
4. Are you currently serving in the military? ( |
) No |
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) Yes |
5.If you are currently eligible to supervise LPCA’s please provide date of completion of required supervision training: Date of Board Approved Supervision Training
CERTIFICATE OF COMPLIANCE
I do certify under penalty of law that the information contained herein is true, correct, and complete to the best of my knowledge and belief. I am aware that, should investigation at any time disclose any such misrepresentation or falsification, my license could be subject to disciplinary action by the Kentucky Board of Licensed Professional Counselors
I have completed |
hours of continuing education during the annual period for renewal as defined in 201 KAR 36:030. |
If your renewal application indicates that you have been selected for AUDIT please send copies of evidence ofhaving completed 10
hours ofcontinuing education as defined in 201 KAR 36:030.
Signature: |
Date: |
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(Sign your name - Do not print or type) |
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