Dhp.virginia.gov/counseling QUARTERLY EVALUATION FOR LPC LICENSURE Section 115-20-52-D-3 of the Virginia LPC regulations requires that the applicant s supervisor provide quarterly evaluations to the resident. This form must be signed and dated by the supervisor. This form is to be completed by the supervisor each quarter and provided to the resident to be held in their possession until they are ready to submit their licensure application. Name of Applicant Last First Middle Applicant s Email Address SUPERVISOR S EVALUATION Supervisor s Name Last First License Number License Type Business Name and Address of Residency Work Site Where Clinical Hours Were Obtained ONE LOCATION ONLY Dates of supervision From mm/dd/yy All Columns Must Be Completed To mm/dd/yy Hours per week Hours are duplicated on another supervisor s quarterly form Total hours Total hours of supervised residency face-to-face client contact hour ancillary hours How many Face-to-face Client Contact hours did the resident pro....
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How to fill out the VA Quarterly Evaluation For LPC Licensure online
The VA Quarterly Evaluation For LPC Licensure is an essential document for applicants seeking licensure as professional counselors in Virginia. Following this guide will help ensure that you complete the form accurately and efficiently.
Follow the steps to fill out the form with confidence.
- Press the ‘Get Form’ button to access the VA Quarterly Evaluation For LPC Licensure form. Open it in the appropriate online editor.
- Begin by filling in your name as the applicant in the designated fields (last, first, and middle). Ensure that you also include your email address for correspondence.
- Under the supervisor’s evaluation section, enter the supervisor’s name and the business name of the residency work site. Specify the location where you completed your clinical hours.
- Input the dates of supervision, including the start date (FROM MM/DD/YY) and the end date (TO MM/DD/YY). Ensure all columns are filled out accurately.
- Provide the license number associated with the supervisor and reenter the address of the residency work site.
- Document the average hours worked per week and total hours for the current quarter, which includes face-to-face client contact hours and ancillary hours.
- Record the number of individual and group supervision hours received. Indicate whether any hours are duplicated on another form by selecting 'Yes' or 'No'.
- Answer the questions regarding the competencies demonstrated under direct supervision. Use 'Yes' or 'No' to respond to each competency question.
- If there are any concerns about the competency of the resident, please provide details on a separate page.
- Finalize the document with signatures. The resident should sign and date, followed by the supervisor's signature and date.
- Once completed, save any changes made to the form. You may choose to download, print, or share the form as required.
Take the next step towards your licensure by completing the VA Quarterly Evaluation For LPC Licensure online today.
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