Get (804) 367-4610 (tel)

Filling out the (804) 367-4610 (Tel) form online is a straightforward process designed to assist applicants in documenting their quarterly evaluations for LPC licensure. This guide provides detailed instructions to help you complete and submit the form accurately.

Follow the steps to fill out the (804) 367-4610 (Tel) form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Start by entering the name of the applicant in the format of Last, First, and Middle. Ensure that this field is accurately completed to identify the individual seeking licensure.
3. Input the applicant's email address to facilitate communication regarding the form and any further requirements.
4. In the supervisor’s evaluation section, enter the supervisor's name in the Last, First format, followed by their license number and license type.
5. Provide the business name and address of the residency work site where the clinical hours were obtained, ensuring to select only one location.
6. Fill in the dates of supervision by entering the start date in mm/dd/yy format and the end date in the same format.
7. Complete the hours per week and total hours fields to reflect the actual hours worked during the supervision period.
8. Indicate if hours are duplicated on another supervisor’s quarterly form by selecting 'Yes' or 'No'.
9. Detail the total hours of supervised residency, specifying the face-to-face client contact hours and ancillary hours.
10. Fill in the questions regarding face-to-face client contact hours provided, individual supervision hours received, and group supervision hours received with appropriate responses.
11. Indicate whether the applicant provided assessment, diagnosis, treatment planning, case management, and demonstrated competencies by selecting 'Yes' or 'No' for each criterion.
12. If there are any concerns regarding the competency of the resident, note them and provide explanations on a separate page if needed.
13. The supervisor must sign and date the form before submission.
14. Once all fields are completed and reviewed for accuracy, save any changes, download the completed form, print it if necessary, or share it as required.

Complete your documents online with confidence and ease!