TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING
NOTICE: The following forms have been filed by the Board of Counseling. The forms are available for public inspection at the Department of Health Professions, 9960 Mayland Drive, Suite 300, Richmond, Virginia 23233, or at the Office of the Registrar of Regulations, General Assembly Building, 2nd Floor, Richmond, Virginia 23219. Copies of the forms may be obtained from Elaine Yeatts, Agency Regulatory Coordinator, Department of Health Professions, 9960 Mayland Drive, Suite 300, Richmond, VA 23233, telephone (804) 367-4688, or email elaine.yeatts@dhp.virginia.gov.
Titles of Regulations: 18VAC115-20. Regulations Governing the Practice of Professional Counseling.
18VAC115-30. Regulations Governing the Certification of Substance Abuse Counselors and Substance Abuse Counseling.
18VAC115-40. Regulations Governing the Certification of Rehabilitation Providers.
18VAC115-50. Regulations Governing the Practice of Marriage and Family Therapy.
18VAC115-60. Regulations Governing the Practice of Licensed Substance Abuse Treatment Practitioners.
FORMS (18VAC115-20)
License Renewal Notice and Application (rev. 7/04).
Registration of Supervision, LPC Form 1– Post Graduate Degree Supervised Experience, (rev. 8/08).
Quarterly Evaluation, LPC Form 1-QE (rev. 8/08).
Licensure Verification of Out-of-State Supervisor, LPC Form 1-LV (rev. 8/08).
Licensure Application, LPC Form 2 (rev. 8/08).
Verification of Supervision – Post-Graduate Degree Supervised Experience, Form LPC 2-VS (rev. 8/08).
Coursework Outline Form, Form LPC 2-CO (rev. 8/08).
Verification of Internship Hours Towards the Residency, Form LPC 2-IR (rev. 8/08).
Verification of Internship, Form LPC 2-VI (rev. 8/08).
Verification of Licensure, Form LPC 2-VL (rev. 8/08).
Supervision Outline Form – Examination Applicants Only, Form LPC 2-SO (rev. 8/08).
Verification of Clinical Practice, Endorsement Applicants Only, Form LPC-ECP (rev. 8/08).
Continuing Education Summary Form (LPC) (rev. 8/07).
Application for Reinstatement of a Lapsed License (eff. 11/03 rev. 8/07).
FORMS (18VAC115-30)
Certification Application for Certification as a – Certified Substance Abuse Counselor, Form 1 (rev. 10/02 1/08).
Registration of Supervision – Form 1 (rev. 1/08).
Substance Abuse Counselor Verification of Supervision, Form 3 CSAC-2VS (rev. 10/02 1/08).
Supervisor's Experience and Education, Form 3A (eff. 10/02).
Licensure or Certification Verification of Out-of-State Supervisor, Form 4 CSAC-LV, (eff. 10/02 rev. 1/08).
Substance Abuse Education Outline, Form CSAC-EO (rev. 1/08).
Substance Abuse Education Tasks, Form CSAC-ET (rev. 1/08).
CSAC-A Certification Application for Certification as a Substance Abuse Counseling Assistant, Form 1A (eff. 10/02 rev. 8/08).
Substance Abuse Certification Verification of Licensure/Certification Verification of Applicant, Form 2 CSAC-VL (eff. 10/02 rev. 1/08).
Application for Reinstatement of a Lapsed Certification (eff. 10/02 rev. 8/07).
Renewal Notice and Application, 0710 (rev. 3/03).
Renewal Notice and Application, CSAC Assistant (rev. 3/03).
FORMS (18VAC115-40)
Application for Certification as a Rehabilitation Provider, CRPAPP Form 1 (rev. 10/99 8/07).
General Information for Certification as a Rehabilitation Provider (eff. 3/98 rev. 8/07).
Verification of Experience for Rehabilitation Provider Certification, Form 2 (eff. 3/98 rev. 8/07).
Rehabilitation Provider Verification of Licensure/Certification, Form 3 (eff. 3/98 rev. 8/07).
Licensure/Certification Verification of Out-of-State Supervisor, Form 4 (eff. 3/98 rev. 8/07).
Rehabilitation Provider Application for Reinstatement of a Lapsed Certificate (rev. 8/07).
Renewal Notice and Application (rev. 2/00).
FORMS (18VAC115-50)
Marriage and Family Therapist Licensure Application, MFT Form 1 2 (rev. 11/03 8/08).
Licensure Verification of Applicant Licensure, MFT Form 2-VL (rev. 11/03 8/08).
Verification of Supervision for Marriage and Family Therapist Licensure – Post-Graduate Degree Supervised Experience, MFT Form 3 2-VS (rev. 11/03 8/08).
Licensure Verification of Out-of-State Supervisor, MFT Form 4 1-LV (rev. 11/03 8/08).
Quarterly Evaluation, MFT Form 1-QE (rev. 8/08).
Courses Coursework Outline Form for Marriage and Family Therapist Licensure, MFT Form 5 2-CO (rev. 11/03 8/08).
Verification of Internship, MFT Form 6 2-VI (rev. 11/03 8/08).
Verification of Internship Hours Towards the Residency, MFT Form 7 2-IR (rev. 11/03 8/08).
Supervision Outline Form for Marriage and Family Endorsement Examination Applicants Only, MFT Form 8 2-SO (rev. 11/03 8/08).
Verification of Clinical Practice, Endorsement Applicants Only, Form MFT-ECP (rev. 8/08).
Registration of Supervision for - Marriage and Family Therapist Licensure, MFT Form A 1 (rev. 11/03 8/08).
Application for Reinstatement of a Lapsed License (eff. 11/03 rev. 8/07).
Continuing Education Summary Form (LMFT) (rev. 8/07).
General Information for Licensure as a Marriage and Family Therapist (eff. 11/03).
Application Instructions -- Licensure by Examination (eff. 11/03).
Application Instructions -- Licensure by Endorsement (eff. 11/03).
License Renewal Notice and Application (rev. 7/04).
FORMS (18VAC115-60)
Licensed Substance Abuse Treatment Practitioner Licensure Application, LSATP Form 1 2 (rev. 11/03 8/08).
General Information for Licensure as a Substance Abuse Treatment Practitioner (rev. 11/03).
Verification of Competency for Independent Practice of Substance Abuse Treatment (TLW) (rev. 11/03).
Licensure/Certification Verification of Applicant Licensure, Form 2 LSATP 2-VL (rev. 11/03 8/08).
Verification of Supervision for Substance Abuse Treatment Practitioner Licensure – Post Graduate Degree Supervised Experience, LSATP Form 3 2-VS (rev. 11/03 8/08).
Supervisor's Experience and Education, Form 3A (rev. 11/03 8/08).
Licensure Verification of Out-of-State Supervisor, LSATP Form 4 1-LV (rev. 11/03 8/08).
Courses Coursework Outline Form for Substance Abuse Treatment Practitioner Licensure, Form 5 LSATP 2-CO (rev. 11/03 8/08).
Graduate Course/Hour Outline Form for Substance Abuse Treatment Practitioner Licensure (TLW) (rev. 11/03).
Verification of Internship, Form 6 LSATP 2-VI (rev. 11/03 8/08).
Verification of Internship Hours Towards the Residency, Form 7 LSATP 2-IR (rev. 11/03 8/08).
Registration of Supervision for Substance Abuse Treatment Practitioner Licensure – Post Graduate Degree Supervised Experience, LSATP Form A 1 (rev. 11/03 8/08).
Quarterly Evaluation Form, LSATP Form C 1-QE (rev. 11/03 8/08).
Supervision Outline Form for Substance Abuse Treatment Practitioner Endorsement Applicants – Examination Applicants Only, Form 8 LSATP 2-SO (rev. 11/03 8/08).
Verification of Clinical Practice, Endorsement Applicants Only, Form LSATP-ECP (rev. 8/08).
License Renewal Notice and Application (rev. 7/04).
Licensed Substance Abuse Treatment Practitioner Application for Reinstatement of a Lapsed License Certificate (rev. 11/03 rev. 8/07).
Substance Abuse Treatment Practitioner Application for Reinstatement Following Disciplinary Action, SATPREDISC (rev. 1/03).
Continuing Education Summary Form (LSATP) (rev. 8/07).
VA.R. Doc. No. R09-1581; Filed August 27, 2008, 12:01 p.m.