INSTRUCTIONS
LPC VERIFICATION OF POST-DEGREE COUNSELING EXPERIENCE
All sections of the Verification form must be completed, unless otherwise noted. If additional space is
required, please include the information on an additional sheet of paper and attach to the form. A Verification
of Post Degree Counseling Experience form is required for each supervisor and for each site. Do not
combine sites and hours on a single form. This form documents supervised counseling experience after a
master’s degree has been conferred. Do not list practicum, internship, or field experience obtained as part of
the course of study within a master’s degree. Failure to complete all sections this form may result in a delay in
reviewing the application for licensure. If you are applying based upon a specialist or doctoral degree see
Special Note on page 2 of these instructions.
SECTION I – APPLICANT DATA
Section I must be completed by the applicant for licensure as it relates to personal data. The applicant must
complete this section and give/send this form to the licensure supervisor with a copy of these instructions.
SECTION II – SUPERVISOR SECTION (Must be completed by the licensure supervisor)
Section II relates to the supervised counseling experience. With a master’s degree the applicant is required to
complete 3,000 total hours of counseling and counseling related duties, 1,200 hours direct client contact, AND
24 months of supervised counseling experience.
Number 9. Enter the name of the location/business/agency the applicant provided counseling. In Date from
(Month/Yr) enter the month and year supervision was approved by the Committee and in Date To (Month/Yr)
enter the month and year supervision was completed. If supervision is being submitted from another state,
enter the date supervision was effective and ended in that state. NOTE: An applicant must remain under
supervision until licensed as a professional counselor.
Computing hours for 9A and 9B.
i. Determine start and end dates of the supervision and the number of weeks comprising that time
period. If supervised in Missouri, the applicant and supervisor should have a letter from the
Committee indicating the effective date of licensure supervision.
For ease of calculation all months have four weeks.
ii. Determine number of hours per week applicant was involved in direct client contact and
counseling related activities.
iii. Multiply the number of weeks by the number of hours per week to obtain total hours of direct
client contact and total hours of counseling experience.
Example: Applicant is approved for supervision effective January 1, 2005 and changes supervisors on
July 1, 2005. On the average the applicant was engaged in direct client contact twenty hours per week
within a forty hour work week.
Direct client contact hours for 6 months = 24 weeks (6x4) x 20 hours per week = 480 hours of direct
client contact.
Total hours for 6 months = 24 weeks (6x4) x 40 hours per week = 960 hours
If supervision is discontinued due to the applicant’s illness, family situation etc. the supervisor must adjust the
number of weeks and corresponding hours accordingly.
10A. Enter the number of hours of direct client contact. Direct client contact is defined as face-to-face
counseling provided to an individual or group of individuals.
10B. Enter the total number of hours (includes direct client contact) the applicant was engaged in counseling
or counseling related duties. This does not include travel time to a work site or supervisor’s office.
If supervision was registered and approved by the Committee prior to June 30, 2005 face-to-face supervisory
meetings were required once a week for one hour. If group supervision was provided the hours count toward
the total hours of counseling experience.
LPC Verification of Post Degree Counseling Experience
Instructions
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Effective June 30, 2005 supervision registered and approved by the committee can include up to 50% group
supervision.
10C. If “No” is checked, please provide an explanation on a separate sheet of paper and attach the sheet
to the form.
If “Yes” is checked the supervisor must provide a breakdown of the percentage of time spent in individual
versus group supervision. As of June 30, 2005 supervision registered and approved by the committee must
consist of at least 50% one hour, face-to-face individual meetings with the applicant per week. The remaining
supervisory meetings can be a combination of individual and/or group supervision. Group supervision is
defined as supervisory meetings with no more than three counselors-in-training or provisional licensed
professional counselors.
Number 11. This section provides an overview of the types of counseling services provided by the applicant.
If a job responsibility/duty is not on this list please list any other duties in the “Other” category or attach a
separate sheet of paper describing those duties.
Number 12. If the supervisor was unable to sign the applicant’s reports, treatment plans, case notes etc. a
brief explanation is needed on how the supervisor and applicant documented review of records and tracked
client or group progress.
Number 13 & 14. This section relates to the overall performance of the applicant. If a supervisor has
reservations regarding applicant, a separate letter must be attached to this form explaining the supervisor’s
concerns.
SECTION III – SUPERVISOR ATTESTATION
The supervisor must read the statement and sign the form. Signing and dating this form verifies that the
supervisor has completed the form to best of her/his knowledge and recollection.
Special Note: Individuals applying based upon a specialist or doctoral degree and completing an internship in
another state may submit those hours to the committee to determine if such hours can be counted toward
licensure. Please contact the committee for more details.
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LPC Verification of Post Degree Counseling Experience
Instructions
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