18VAC115-40 Regulations Governing the Certification of Rehabilitation Providers

REGULATIONS

Vol. 27 Iss. 25 - August 15, 2011

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

BOARD OF COUNSELING

Chapter 40

Forms

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.

Agency Contact: Elaine J. Yeatts, Agency Regulatory Coordinator, Department of Health Professions, 9960 Mayland Drive, Suite 300, Richmond, VA 23233, telephone [phone], FAX [phone], or email [e-mail].

NOTICE: The following forms used in administering the regulations were filed by the agency. The forms are not being published; however, online users of this issue of the Virginia Register of Regulations may click on the name to access a form. The forms are also available through the agency contact or at the Office of the Registrar of Regulations, General Assembly Building, 2nd Floor, Richmond, Virginia 23219.

FORMS (18VAC115-20)

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 Post-Licensure Clinical Practice, Endorsement Applicants Only, Form LPC-ECP (rev. 8/09).

Continuing Education Summary Form (LPC) (rev. 8/07).

Registration of Supervision - Post Graduate Degree Supervised Experience, LPC Form 1 (rev. 2/11).

Quarterly Evaluation, LPC Form 1-QE (rev. 2/11).

Licensure Verification of Out-of-State Supervisor, LPC Form 1-LV (rev. 2/11).

Licensure Application, LPC Form 2 (rev. 2/11).

Verification of Supervision – Post-Graduate Degree Supervised Experience, LPC Form 2-VS (rev. 2/11).

Coursework Outline Form, LPC Form 2-CO (rev. 2/11).

Verification of Internship Hours Towards the Residency, LPC Form 2-IR (rev. 2/11).

Verification of Internship, LPC Form 2-VI (rev. 2/11).

Verification of Licensure, LPC Form 2-VL (rev. 2/11).

Supervision Outline - Examination Applicants Only, LPC Form 2-SO (rev. 2/11).

Verification of Clinical Practice, 5 of Last 6 Years Immediately Preceding Submission of Application for Licensure, LPC Form-ECP (rev. 2/11).

Continuing Education Summary Form (LPC) (rev. 3/09).

Application for Reinstatement of a Lapsed License (rev. 8/07).

Application for Reinstatement of a Revoked, Suspended, or Surrendered License (rev. 8/07).

FORMS (18VAC115-30)

Certification Application – Certified Substance Abuse Counselor (rev. 1/08).

Registration of Supervision – Form 1 (rev. 1/08).

Verification of Supervision, Form CSAC-2VS (rev. 1/08).

Licensure Verification of Out-of-State Supervisor, Form CSAC-LV, (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, (rev. 8/08).

CSAC-A Certification Application (rev. 8/09).

Substance Abuse Education Outline, Form CSAC-A-EO (rev. 8/09).

Substance Abuse Education Tasks, Form CSAC-A-ET (rev. 8/09).

Verification of Licensure/Certification, Form CSAC-VL (rev. 1/08).

Application for Reinstatement of a Lapsed Certification (rev. 8/07).

FORMS (18VAC115-40)

Application for Certification as a Rehabilitation Provider, Form 1 (rev. 8/07).

General Information for Certification as a Rehabilitation Provider (rev. 8/07).

General Information for Certification as a Rehabilitation Provider (rev. 7/11).

Verification of Experience for Rehabilitation Provider Certification, Form 2 (rev. 8/07).

Rehabilitation Provider Verification of Licensure/Certification, (rev. 8/07).

Licensure/Certification Verification of Out-of-State Supervisor, Form 4 (rev. 8/07).

Rehabilitation Provider Application for Reinstatement of a Lapsed Certificate (rev. 8/07).

FORMS (18VAC115-50)

Marriage and Family Therapist Licensure Application, MFT Form 2 (rev. 8/08).

Verification of Licensure, MFT Form 2-VL (rev. 8/08).

Verification of Supervision – Post-Graduate Degree Supervised Experience, MFT Form 2-VS (rev. 8/08).

Licensure Verification of Out-of-State Supervisor, MFT Form 1-LV (rev. 8/08).

Quarterly Evaluation, MFT Form 1-QE (rev. 8/08).

Coursework Outline Form for Marriage and Family Therapist Licensure, MFT Form 2-CO (rev. 8/08).

Verification of Internship, MFT Form 2-VI (rev. 8/08).

Verification of Internship Hours Towards the Residency, MFT Form 2-IR (rev. 8/08).

Supervision Outline Examination Applicants Only, MFT Form 2-SO (rev. 8/08).

Verification of Post-Licensure Clinical Practice, Endorsement Applicants Only, Form MFT-ECP (rev. 8/09).

Registration of Supervision Instructions (rev. 4/09).

Registration of Supervision for Marriage and Family Therapist Licensure, Form A (rev. 4/09).

Licensure Application - Marriage and Family Therapist, MFT Form 2 (rev. 2/11).

Verification of Licensure, MFT Form 2-VL (rev. 2/11).

Verification of Supervision – Post-Graduate Degree Supervised Experience, MFT Form 2-VS (rev. 2/11).

Licensure Verification of Out-of-State Supervisor, MFT Form 1-LV (rev. 2/11).

Quarterly Evaluation, MFT Form 1-QE (rev. 2/11).

Coursework Outline Form, MFT Form 2-CO (rev. 2/11).

Verification of Internship, MFT Form 2-VI (rev. 2/11).

Verification of Internship Hours Towards the Residency, MFT Form 2-IR (rev. 2/11).

Supervision Outline - Examination Applicants Only, MFT Form 2-SO (rev. 2/11).

Verification of Clinical Practice 5 of Last 6 Years Immediately Preceding Submission for Application of Licensure, Endorsement Applicants Only, Form MFT-ECP (rev. 2/11).

Registration of Supervision - Post Graduate Degree Supervised Experience, MFT Form 1 (rev. 2/11).

Application for Reinstatement of a Lapsed License (rev. 8/07).

Continuing Education Summary Form (LMFT) (rev. 8/07).

Continuing Education Summary Form (LMFT) (rev. 3/09).

FORMS (18VAC115-60)

Licensed Substance Abuse Treatment Practitioner Licensure Application, LSATP Form 2 (rev. 8/08).

Verification of Licensure, Form LSATP 2-VL (rev. 8/08).

Verification of Supervision – Post Graduate Degree Supervised Experience, LSATP 2-VS (rev. 8/08).

Supervisor's Experience and Education, (rev. 8/08).

Licensure Verification of Out-of-State Supervisor, LSATP Form 1-LV (rev. 8/08).

Coursework Outline Form, Form LSATP 2-CO (rev. 8/08).

Verification of Internship, Form LSATP 2-VI (rev. 8/08).

Verification of Internship Hours Towards the Residency, Form LSATP 2-IR (rev. 8/08).

Registration of Supervision – Post Graduate Degree Supervised Experience, LSATP Form 1 (rev. 8/08).

Quarterly Evaluation Form, LSATP Form 1-QE (rev. 8/08).

Supervision Outline Form – Examination Applicants Only, Form LSATP 2-SO (rev. 8/08).

Verification of Post-Licensure Clinical Practice, Endorsement Applicants Only, Form LSATP-ECP (rev. 8/09).

Licensed Substance Abuse Treatment Practitioner Application for Reinstatement of a Lapsed Certificate (rev. 8/07).

Continuing Education Summary Form (LSATP) (rev. 8/07).

Licensure Application, Licensed Substance Abuse Treatment Practitioner, LSATP Form 2 (rev. 1/11).

Verification of Licensure, Form LSATP 2-VL (rev. 1/11).

Verification of Supervision – Post Graduate Degree Supervised Experience, LSATP 2-VS (rev. 1/11).

Supervisor's Experience and Education (rev. 1/11).

Licensure Verification of Out-of-State Supervisor, LSATP Form 1-LV (rev. 1/11).

Coursework Outline Form, Form LSATP 2-CO (rev. 1/11).

Verification of Internship, Form LSATP 2-VI (rev. 1/11).

Verification of Internship Hours Towards the Residency, Form LSATP 2-IR (rev. 1/11).

Registration of Supervision – Post Graduate Degree Supervised Experience, LSATP Form 1 (rev. 1/11).

Quarterly Evaluation Form, LSATP Form 1-QE (rev. 1/11).

Supervision Outline Form – Examination Applicants Only, Form LSATP 2-SO (rev. 1/11).

Verification of Post-Licensure Clinical Practice, Endorsement Applicants Only, Form LSATP-ECP (rev. 1/11).

Licensed Substance Abuse Treatment Practitioner Application for Reinstatement of a Lapsed Certificate (rev. 7/11).

Continuing Education Summary Form (LSATP) (rev. 3/09).

VA.R. Doc. No. R11-2945; Filed July 27, 2011, 1:48 p.m.