prof.-application for licensure...new jersey office of the attorney general. division of consumer...

New Jersey Office of the Attorney GeneralDivision of Consumer Affairs

State Board of Marriage and Family Therapy ExaminersProfessional Counselor Examiners Committee124 Halsey Street, 6th Floor, P.O. Box 45044

Newark, New Jersey 07101(973) 504-6582

Application for Licensure Professional Counselor/Rehabilitation Counselor/Associate Counselor

Date:____________________________

Anonrefundableapplicationfilingfeeof$75,intheformofacheckormoneyordermadeouttotheStateofNewJersey,mustbesubmittedwiththisapplication.(Applicantsshouldunderstandthatiftheapplicationfilingfeeispaidwithapersonalcheck,andthecheckisreturnedbythebankduetoinsufficientfunds,thenextstepinthelicensureorcertificationprocesswillbedelayeduntilthefeeispaid.)

TheDivisionisprecludedbylawfromdisclosingtothepublictheplaceofresidenceoflicenseesorapplicants,without theirconsent.However,you are requiredtoprovideanaddressthatmaybereleasedtothepublicinour directories orinresponsetootherrequests(byputtingacheckintheappropriatebox). Ifyouprovideyourplaceofresidenceasyourpublicaddressofrecord,wewillassumethatyouhaveconsentedtohavethataddressbedisclosed. Ifyoudonotconsenttothedisclosureofyourplaceofresidence,youshouldprovide anaddressofrecordotherthanyour place ofresidencethatmaybereleasedtothepublic.Oneofyouraddressesmustincludeastreet,city,stateandZIPcode.

Information that youprovideon this applicationmaybe subject to public disclosure as requiredby theOpenPublicRecordsAct(OPRA).

Please print clearly. You must answer all of the questions on this application.

Personal Information Dateofbirth:_________________________ MonthDayYear

Placeofbirth:________________________ CityStateCountry

Mr.1. Name Mrs.________________________________________________________________ (_______________________) Ms. Lastname Firstname Middleinitial Maidenname

2. Address

Home:______________________________________________________________________________________________ StreetorP.O.Box City State ZIPcode County

_____________________________________ ___________________________________ Telephonenumber(includeareacode) E-mailaddress

Business:____________________________________________________________________________________________ Nameofcompany Telephonenumber(includeareacode)

____________________________________________________________________________________________ Street City State ZIPcode County

Mailing: ____________________________________________________________________________________________ StreetorP.O.Box City State ZIPcode County

Attachaclear,full-facepassport-stylephotograph(2˝x2˝)ofyourheadandshoulders,takenwithinthepastsixmonths.A photo is requiredwith eachapplication.

Donotuse staples toattach thephoto.

What are you applying for? Authorizationtositforthe

NationalCounselorExam LicensureasanAssociate

Counselor LicensureasaProfessional

Counselor Licensureasa

RehabilitationCounselor

LicensurebyReciprocity

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Application Categories

Iherebyapplyforthefollowingtypeoflicense:(Pleasechecktheappropriateboxes.)

Licensed Associate Counselor (LAC)

Educational Requirements: Completionofaminimumof60graduatesemesterhours inaplannededucationalprogram,whichincludesamaster’sdegreeordoctorateincounselingfromaregionallyaccreditedinstitutionofhighereducation,ofwhich45graduatesemesterhoursaredistributedinatleasteightoftheidentifiedareassetforthinN.J.A.C.13:34-11.5.

Supervised Experience: Notrequiredforlicensureasalicensedassociatecounselor.

Examination required:

NationalCounselorExamination(NCE)

Licensed Professional Counselor (LPC)

Educational Requirements: Completionofaminimumof60graduatesemesterhours inaplannededucationalprogram,whichincludesamaster’sdegreeordoctorate incounselingfromaregionallyaccredited institutionofhighereducation,ofwhich45graduatesemesterhoursaredistributedinatleasteightoftheidentifiedareassetforthinN.J.A.C.13:34-11.2and11.3.

Supervised Experience (Check One): Pursuant to N.J.A.C. 13:34-11.2 (b) and (c) through 13:34.11.3 (a), (b) and (c).

Option A Option B

4,500hours 3,000hours+30graduatesemesterhoursbeyondthe60credit master’sdegreeinareasclearlyrelatedtocounseling.

AssetforthinN.J.A.C.13:34-11.3.

Examination required: Examination required:

NationalCounselorExamination(NCE) NationalCounselorExamination(NCE)

Licensed Rehabilitation Counselor (LRC)

Educational Requirements: Completionofamaster’sdegreeinrehabilitationcounselingfromaregionallyaccreditedinstitutionofhighereducation,whichincludescourseworkintheidentifiedareassetforthatN.J.A.C.13:34-21.3.

Supervised Experience:

3,000hours+30graduatesemesterhoursbeyondthemaster’sdegreeinareasclearlyrelatedtorehabilitationcounselingassetforthinN.J.A.C.13:34-21.3through(a)10.

Examination required:

CertifiedRehabilitationCounselorExamination(CRCE)

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3. SocialSecurityNumber YoumustprovideyourSocialSecuritynumbertotheBoardorCommittee.Failuretodosowillresultindenial/nonrenewalof licensureorcertification.

*SocialSecurityNumber: __________ -____________ -___________

*PursuanttoN.J.S.A.54:50-24etseq.oftheNewJerseytaxationlaw,N.J.S.A.2A:17-56.44eoftheNewJerseyChildSupportEnforcementLaw,Section1128E(b)(2)AoftheSocialSecurityActand45C.F.R.60.7,60.8and60.9,theBoardorCommitteeisrequiredtoobtainyourSocialSecuritynumber.Pursuanttotheseauthorities,theBoardorCommitteeisalsoobligatedtoprovideyourSocialSecuritynumberto:

a. theDirectorofTaxationtoassistintheadministrationandenforcementofanytaxlaw,includingforthepurposeofreviewing compliancewithStatetaxlawandupdatingandcorrectingtaxrecords;

b. theProbationDivisionoranyotheragencyresponsibleforchildsupportenforcement,uponrequest;and

c. theNational PractitionerDataBank and theH.I.P.DataBank,when reporting adverse actions relating to health care professionals.

4. Citizenship/ImmigrationStatus

FederallawlimitstheissuanceorrenewalofprofessionaloroccupationallicensesorcertificatestoU.S.citizensorqualifiedaliens. Tocomplywiththisfederallaw,checktheappropriateboxbelowwhichindicatesyourcitizenship/immigrationstatus.Ifyouarenot aU.S.citizen,attachacopyofyouralienregistrationcard(frontandback)orotherdocumentationissuedbytheofficeofU.S. CitizenshipandImmigrationServices(USCIS).

U.S.citizen AlienlawfullyadmittedforpermanentresidenceinU.S. Otherimmigrationstatus

Questionsaboutyourimmigrationstatusandwhetherornotitisaqualifyingstatusunderfederallawshouldbedirectedtothe USCISat:1-800-375-5283.

5. ChildSupport

Pleasecertify,underpenaltyofperjury,thefollowing:

a. Doyoucurrentlyhaveachild-supportobligation? Yes No

(1)If“Yes,”areyouinarrearsinpaymentofsaidobligation? Yes No

(2)If“Yes,”doesthearrearagematchorexceedthetotalamountpayableforthepastsixmonths? Yes No

b. Haveyoufailedtoprovideanycourt-orderedhealthinsurancecoverageduringthepastsixmonths? Yes No

c. Haveyoufailedtorespondtoasubpoenarelatingtoeitherapaternityorchild-supportproceeding? Yes No

d. Areyouthesubjectofachild-support-relatedarrestwarrant? Yes No

InaccordancewithN.J.S.A.2A:17-56.44d,ananswerof“Yes”toanyofthequestionsa(1)throughdwillresult inadenialoflicensureorcertification.Furthermore,anyfalsecertificationoftheabovemaysubjectyoutoapenalty,including,butnotlimitedto,immediaterevocationorsuspensionoflicensureorcertification.

___________________________________ ___________________________________ ________________________ Applicant’sname(pleaseprint) Applicant’ssignature Date

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6. IllegalUseofControlledDangerousSubstances

Thequestionbelowpertainstotheillegaluseofcontrolleddangeroussubstances.Pleasereadthedefinitionscarefully.Yourresponseswillbetreatedconfidentiallyandretainedseparately.Pleasebeawarethatyouhavetherighttoelectnottoanswerthisquestionifyouhavereasonablecausetobelievethatansweringmayexposeyoutothepossibilityofcriminalprosecution.Inthatevent,youmayasserttheFifthAmendmentprivilegeagainstself-incrimination.AnyclaimofFifthAmendmentprivilegemustbemadeingoodfaith.IfyouchoosetoasserttheFifthAmendment,youmustdosoinwriting.Youmustfullyrespondtoallotherquestionsontheapplication.YourapplicationforlicensureorcertificationwillbeprocessedifyouclaimtheFifthAmendmentprivilegeagainstself-incrimination.Youshouldbeaware,however,thatyoumaylaterbedirectedbytheAttorneyGeneraltoansweraquestionthatyouhaverefusedtoansweronthebasisontheFifthAmendment,providedthattheAttorneyGeneralfirstgrantsyouimmunityaffordedbystatutorylaw,(N.J.S.A.45:1-20).

“Currently”doesnotmeanonthedayof,orevenintheweeksormonthsprecedingthecompletionofthisapplication.Rather,itmeansrecentlyenoughsothattheuseofdrugsmayhaveanongoingimpactonone’sfunctioningasalicensee,orwithintheprevious365days,whicheverislonger.

“Illegal use of controlled dangerous substance”meanstheuseofacontrolleddangeroussubstanceobtainedillegally(e.g.heroinorcocaine)aswellastheuseofcontrolleddangeroussubstanceswhicharenotobtainedpursuanttoavalidprescriptionornottakeninaccordancewiththedirectionsofalicensedhealthcarepractitioner.

a. Areyoucurrentlyengagedintheillegaluseofcontrolleddangeroussubstances?(Asstatedabove,“currently”isdefinedas “recentlyenough…[to]haveanongoingimpact…”or“withintheprevious365days,”whicheverislonger.)

Yes No

Ifyouanswered“Yes,”areyoucurrentlyparticipatinginasupervisedrehabilitationprogramorprofessionalassistanceprogram thatmonitorsyouinordertoassurethatyouarenotengagingintheillegaluseofcontrolleddangeroussubstances?

Yes No

_____________________________________________________ ___________________________________ Applicant’ssignature Date

7. Have you taken the National Counselor Examination? Yes ______________No When:

If “Yes,” did you pass the examination? Yes No

A copy of your exam scores is required. Please have the National Board of Certified Counselors forward an official copy directly tothe Committee.

8. Have you taken the Certified Rehabilitation Counselor Examination? Yes No

If “Yes,” did you pass the examination? Yes No

A copy of your exam scores is required. Please have the Commission on Rehabilitation Counselor Certfication forward an officialcopy directly to the Committee.

9. Have you ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted into pre-trial intervention (P.T.I.); or pled guilty to any violation of law, ordinance, felony, misdemeanor or disorderly persons offense, in New Jersey, any other state, the District of Columbia or in any other jurisdiction? (Parking or speeding violations need not be disclosed, but motor vehicle

violations such as driving while impaired or intoxicated must be.) Yes No

10. Have you ever been convicted of any crime or offense under any circumstances? This includes, but is not limited to, a plea of guilty,

non vult, nolo contendere, no contest, or a finding of guilt by a judge or jury. Yes No

If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete

explanation. (Attach additional sheets of paper to this application.)

11. Do you currently hold, or have you ever held a professional license or certificate of any kind in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No

If “Yes,” for each license or certificate held, provide the date(s) held and the number(s). If the license or certificate was issued under a different name, please provide that name. ____________________________________________________________________

First name Last name Middle initial

_____________________ _______________________ ____________________________ ____________________ Number State or jurisdiction that issued the license or certificate Type of license or certificate Date issued/expired

_____________________ _______________________ ____________________________ ____________________Number State or jurisdiction that issued the license or certificate Date issued/expired Type of license or certificate



12. Have you ever been cited for disciplinary reasons or denied a professional license or certificate of any kind in New Jersey, any otherstate, the District of Columbia or in any other jurisdiction? Yes No

13. Have you ever had a professional license or certificate of any type suspended, revoked or surrendered in New Jersey, any other state,the District of Columbia or in any other jurisdiction? Yes No

14. Has any action (including the assessment of fines or other penalties) ever been taken against your professional practice by any agencyor certification board in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No

15. Have you ever been named as a defendant in any litigation related to the practice of counseling or other professional practice in NewJersey, any other state, the District of Columbia or in any other jurisdiction? Yes No

16. Are you aware of any investigation pending against a professional license or certificate issued to you by a professional board in NewJersey, any other state, the District of Columbia or in any other jurisdiction? Yes No

17. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any otherjurisdiction? Yes No

18. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional grouprelated to the practice of counseling or other professional practice in New Jersey, any other state, the District of Columbia or in any

other jurisdiction? Yes No

If the answer to any of the above questions, numbers 12 through 18, is “Yes,” provide a complete explanation of the circumstancesleading to the action, and any supporting documentation, on separate sheets of paper.

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Education

1. Listtheregionallyaccreditedgraduateschool(s)youhaveattended,beginningwiththemostrecent.

Note: Allgraduatedegreesandcourseworkmustbedocumentedbyacertifiedtruecopyoftheofficialtranscript.

Checkone: Enclosed Requested,tobesentseparately

Noactionwillbetakenonyourapplicationuntilalltranscriptshavebeenreceived.

Month Year Month Year Nameandaddressofcollegeoruniversity Degree,DiplomaorCertificate (ifany)

_____ _____to_____ _________________________________________________________

____________________________________________________

_______________________________ _____________________

_____ _____to_____ _________________________________________________________

____________________________________________________

_______________________________ _____________________

_____ _____to_____ _________________________________________________________

____________________________________________________

_______________________________ _____________________

_____ _____to_____ _________________________________________________________

____________________________________________________

_______________________________ _____________________

_____ _____to_____ _________________________________________________________

____________________________________________________

_______________________________ _____________________

_____ _____to_____ _________________________________________________________

____________________________________________________

_______________________________ _____________________

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Experience

(To be completed by applicants who seek to become a Licensed Professional Counselor or a Licensed Rehabilitation Counselor only; see attached supervision form.)

a.

Employer’sname Streetaddress

City State ZIPcode Telephonenumber(includeareacode)

Nameofsupervisor(s) Title(s) Licensedesignation

Totalhoursofsupervisedexperience Totalhoursofindividualsupervision Totalhoursofgroupsupervision

From to Month YearMonth Year

Descriptionofjobfunctionsandresponsibilities:

b.







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c.







d.







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Professional Counselor/Associate Counselor Applicant Course Work Check SheetAs set forth in N.J.A.C. 13:34-11.2, the 60 graduate semester hours in course work will include 45 graduatesemesterhoursdistributedineightofthefollowingareas.Pleaselistonly the45creditsonyourtranscript(s)thatsatisfythe8outof9domainareas.Donotlistacoursemorethanonce.

Area Course title and Hours/Credits College/University Course number (Indicate semester or quarter hours) (45 semester credits or 68 quarter hour credits)

Counselingtheory a._________________________ ___________ _____________________andpractice. b._________________________ ___________ _____________________ c._________________________ ___________ _____________________

Thehelping a._________________________ ___________ _____________________relationship. b._________________________ ___________ _____________________ c._________________________ ___________ _____________________

Humangrowthand a._________________________ ___________ _____________________development,and b._________________________ ___________ _____________________maladaptivebehavior. c._________________________ ___________ _____________________

Lifestyleandcareer a._________________________ ___________ _____________________development. b._________________________ ___________ _____________________ c._________________________ ___________ _____________________

Groupdynamics, a._________________________ ___________ _____________________processing,counseling b._________________________ ___________ _____________________andconsulting. c._________________________ ___________ _____________________

Appraisalof a._________________________ ___________ _____________________individuals. b._________________________ ___________ _____________________ c._________________________ ___________ _____________________

Socialandcultural a._________________________ ___________ _____________________foundations. b._________________________ ___________ _____________________ c._________________________ ___________ _____________________

Researchand a._________________________ ___________ _____________________evaluation. b._________________________ ___________ _____________________ c._________________________ ___________ _____________________

Thecounseling a._________________________ ___________ _____________________profession. b._________________________ ___________ _____________________ c._________________________ ___________ _____________________

Totalhours/credits___________

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Licensed Rehabilitation Counselor Applicant Course Work Check SheetAs set forth inN.J.A.C. 13:34-21.2, themaster’s degree in rehabilitation counselingwill include coursework in thefollowingareas.Pleaselistwhichcoursesindicatedonyourtranscript(s)satisfytherelevantareas.Donotlistacoursemorethanonce.

Area Course title and Hours College/University Course number (Indicate semester or quarter hours)

Introductionto a._________________________ ___________ _____________________rehabilitation b._________________________ ___________ _____________________counseling. c._________________________ ___________ _____________________

Counselingtheories a._________________________ ___________ _____________________andtechniques. b._________________________ ___________ _____________________ c._________________________ ___________ _____________________

Personality a._________________________ ___________ _____________________theories. b._________________________ ___________ _____________________ c._________________________ ___________ _____________________

Psychosocialaspects a._________________________ ___________ _____________________ofdisability. b._________________________ ___________ _____________________ c._________________________ ___________ _____________________

Medicalaspects a.___________________________ ___________ _______________________ofdisability. b._________________________ ___________ _____________________ c._________________________ ___________ _____________________

Evaluationand a._________________________ ___________ _____________________assessment. b._________________________ ___________ _____________________ c._________________________ ___________ _____________________

Vocationalaspects a._________________________ ___________ _____________________ofdisability. b._________________________ ___________ _____________________ c._________________________ ___________ _____________________

Rehabilitationcase a._________________________ ___________ _____________________management. b._________________________ ___________ _____________________ c._________________________ ___________ _____________________

Research a._________________________ ___________ _____________________methods. b._________________________ ___________ _____________________ c._________________________ ___________ _____________________

Practicumor a._________________________ ___________ _____________________internship. b._________________________ ___________ _____________________ c._________________________ ___________ _____________________

Totalhours___________-10-

AffidAvit

This affidavit is to be executed by the applicant before a notary public:

Stateof:_____________________________________________

Countyof:___________________________________________

I, ___________________________________________ , inmaking this application to the Professional CounselorExaminersCommitteeforlicensureorcertificationundertheprovisionsofTitle45oftheGeneralStatutesofNewJerseyandtheRulesoftheProfessionalCounselorExaminersCommittee,swear(oraffirm)thatIamtheapplicantandthatallinformationprovidedinconnectionwiththisapplicationistruetothebestofmyknowledgeandbelief.Iunderstandthatanyomissions,inaccuraciesorfailuretomakefulldisclosuresmaybedeemedsufficienttodenylicensureorcertificationortowithholdrenewaloforsuspendorrevokealicenseorcertificateissuedbytheCommittee.

I further swear (or affirm) that I have readN.J.S.A. 45:8B-34 et seq., togetherwith theRules andRegulations of theProfessionalCounselorExaminersCommittee,N.J.A.C.13:34-10.1through31.8,andfullyunderstandthatinreceivinglicensureorcertificationfromtheCommittee,Ibindmyselftobegovernedbythem.

Furthermore, I voluntarily consent to a thorough investigationofmypresent andpast employment andother activitiesforthepurposeofverifyingmyqualificationsforlicensureorcertification.Ifurtherauthorizeallinstitutions,employers,agenciesandallgovernmentalagenciesandinstrumentalities(local,state,federalorforeign)toreleaseanyinformation,filesorrecordsrequestedbytheCommittee.

_____________________________________________ Applicant’ssignature

Swornandsubscribedtobeforemethis_____________

dayof _________________________ ,____________MonthYear

_____________________________________________ NameofNotaryPublic(pleaseprint)

_____________________________________________ SignatureofNotaryPublic

Affix Seal Here

} ss.

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New Jersey Office of the Attorney General

Division of Consumer AffairsState Board of Marriage and Family Therapy Examiners

Professional Counselor Examiners CommitteeP.O. Box 45044

Newark, New Jersey 07101(973) 504-6415

CertifiCAtion And AuthorizAtion form for A CriminAl history BACkground CheCk

Directions:Answerallofthequestionsonthisform.

1. Name _________________________________________________________ ( ________________________) LastFirstMiddle MaidenName

2. Address___________________________________________________________________________________________ StreetorP.O.Box City State ZIPcode

3. Dateofbirth____/____/____ Sex: Male FemaleMonthDayYear

4. SocialSecuritynumber_________/_____ / ________

5. HaveyoucompletedthefingerprintingprocessforanyBoard or Committee of the New Jersey Division of Consumer AffairssinceNovember2003? Yes No

If“No,”youwillreceiveaseparatemailingfromtheBoardorCommitteeregardingthecriminalhistoryrecordbackgroundcheckprocess.Nopaymentisnecessaryasofnow.

If“Yes,”pleaseprovidethefollowinginformationandfollowtheinstructionsoutlinedbelow:

_______________________________________________ _______________________________________________ BoardorcommitteerequiringthefingerprintingMonthandyearyouwerefingerprinted

If youwere fingerprinted afterNovember 2003 as part of the criminal history background process for licensure orcertificationbyanyotherBoard or Committee of the New Jersey Division of Consumer Affairs (abackgroundcheckconductedfortheDepartmentofEducation,anotherstateagencyoranotherstatedoesnotapply)youwillnotberequiredtobefingerprintedasecondtime.However,theDivisionmustperformacriminalhistorybackgroundcheckeachtimeyouapplyforlicensureorcertification.The fee for this service is $18.75. PaymentshouldbemadeintheformofacheckormoneyorderpayabletotheStateofNewJerseyandshouldaccompanyyourapplicationpacket.

6. Haveyoueverbeenarrestedand/orconvictedofacrimeoroffense?(Minortrafficoffensessuchasaparkingorspeedingviolationsneednotbelisted.) Yes No

Every such conviction on record must be disclosed. Atruecopyofeverypolicereport,judgmentofconviction,sentencing orderandterminationofprobationorder,ifapplicable,must besubmittedwiththisform.Anydocuments(includingemployer orsupervisorlettersofreference,ifapplicable)whichpresentclearandconvincingevidenceofrehabilitationmust besubmitted withthisform.Failure to follow these instructions may result in the denial of an initial application. Note: Copiesofjudgments,sentencingandterminationofprobationordersmaybeobtainedfromtheclerkofthecounty wherethoseorders,disposingoftheconviction,wereissuedandfiled. Your continuing responsibility to disclose convictions of crimes or offenses:Youmust notifytheBoardorCommittee withinfive(5)businessdaysifyouareconvictedofanycrimesoroffensesafterthisformhasbeencompleted.

Mr. Mrs. Ms.

BoardorCommittee________________________

Official Use Only

Resubmit________________________

Official Use OnlyDualLicense

LicenseType1________________________

Applicant’sNumber________________________

LicenseType2________________________

Applicant’sNumber________________________

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CACertifi tion

I, ______________________________________________ , in making this application to the Board or Committee for certification or licensure, certify that I am the applicant and that all of the information provided in connection with this application is true to the best of my knowledge and belief. I understand that any omissions, inaccuracies or failure to make full disclosures may be deemed sufficient to deny certification or licensure or to withhold renewal of or suspend or revoke a certificate

or license issued by the Board or Committee.

I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose of verifying my qualifications for certification or licensure. I further authorize all institutions, employers, agencies and all

governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, files or records requested by the Board or Committee.

I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment.

__________________________________________________________ _________________________________ Signature of applicant Date

Rev. 1/2/19 - 13 -

prof.-application for licensure...new jersey office of the attorney general. division of consumer...

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