BRIAN SANDOVAL	NEVADA STATE BOARD OF EXAMINERS FOR	9436 W. Lake Mead Blvd Suite 11-J
Govenor	MARRIAGE & FAMILY THERAPISTS AND	Las Vegas, Nevada 89134-8342
	CLINICAL PROFESSIONAL COUNSELORS	Office: (702) 486-7388
Raymond E. Smith Sr.		Fax: (702) 486-7258
Executive Director		https://marriage.state.nv.us

APPLICATION FOR CLINICAL PROFESSIONAL COUNSELORS LICENSURE

Application Fee: $75.00.

To apply and pay online, please use the form below. To apply and pay by check or mail, please click here

I. APPLICANT IDENTIFICATION INFORMATION: Internship Licensure

1. Last Name	First Name	Middle Name	(Maiden)	Other Names or AKA
2. Home Address	City	State	Zip	Social Security
3. Home Phone Number	Cell Phone Number	Email Address		Date of Birth
4. Primary Employer		Name of Supervisor	Business Telephone	Extension
5. Business Address: Street/P.O. Box/Suite		City	State	Zip

Preferred Mailing Address: Home Office Other Your preferred mailing address may be public information and

may be placed on the Board's website and/or made available to outside organizations. If you do not want your home or

work address available to the public, please provide an alternate mailing address:

PLEASE KEEP A COPY OF ALL RECORDS FOR YOUR FILE.

NAC 641A gives the Board the right to refuse to issue, suspend or revoke any registration, permit or license, of any

licensee or applicant if the candidate secures the license, registration or permit by fraud, deceit or misrepresentation on

any application for licensure submitted to the Board. Please review NRS 641A and NAC 641A from the website

marriage.state.nv.us at the 'About Us' page. Disclosure of your social security number is mandatory pursuant to

42 U.S.C. �666(a)(13) and will be used for tax enforcement purposes, may be used for child support enforcement purposes or

may be provided to a licensing or examination entity which uses a national examination for purposes of verification of

license or examination status.

II. GENERAL INFORMATION:

1. Are you a citizen of the United States? Yes No
2. Are you lawfully entitled to remain in the United States? Yes No	Alien Registration Number:
3. Have you ever filed any application for licensure or registration in Nevada?	Yes No If yes, please answer the following:
a. Which Credential:	When:
Under what name:	State: License Number:
b. Which Credential:	When:
Under what name:	State: License Number:
4. Do you currently hold or have you ever held a license certificate or registration to practice marriage and family therapy in another state or jurisdiction?
	Yes No If yes, please answer the following:
a. Which Credential:	When:
Under what name:	State: License Number:
b. Which Credential:	When:
Under what name:	State: License Number:
5. What is your qualifiing Graduate Degree?	Degree Credits:
6. Name of the School, College, University or Institution:

III. EXAMINATION:

A. If you have not previously taken the National Clinical Mental Health Counseling Examination developed by the National

Board for Certified Counselors and achieved a passing score, you will be notified in writing when

you are eligible to register and sit for the examination. Applicants must first satisfy the Nevada State educational

requirements and obtain a license in order to be authorized by the Board to register for the examination.

B. Did you complete the National CLinical Mental Health Counseling Examination through the Nevada State Board office?

Yes No If you answered 'no', please provide the following:

Name of the state in which you took the National Clinical Mental Health Counseling Examination (Contact the

National Board for Certified Counselors to transfer your official score to Nevada and send an official

copy of your score directly to the Board office.)

Date exam was taken: Location/State of Exam:

IV. BACKGROUND INFORMATION:

1. Have you ever been arrested, charged with, or convicted of, or plead guilty or "nolo contendere" to any offense or violation of
any federal, state or local law, including any foreign country, which is a misdemeanor, gross misdemeanor, or felony,
excluding any minor traffic offense? Please note driving or being in control of a motor vehicle while under the influence of any
chemical substance, including alcohol, is not considered a minor traffic offense.	Yes No
2. Have you ever had a complaint filed with a certifying, licensing, or registering body or any professional association against
you for alleged unethical behavior or unprofessional conduct?	Yes No
3. Have you ever been censured or had any disciplinary action taken against you for unethical behavior, unprofessional conduct
or any other grounds by any certification or licensing board or other agency, institution, or professional organization?
	Yes No
4. Have you ever been investigated, charged with, or convicted of unprofessional conduct, negligence, or professional
incompetence by any certification or licensing board or other agency, institution, or professional organization?
	Yes No
5. Have you used any alcohol, narcotic, barbiturate other drug affecting the central nervous system, or other drug which may
cause physical or psychological dependence, either to which you were addicted or upon which you were dependent within the
last 5 years?	Yes No
6. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with
reasonable skill and safety?	Yes No
7. Have you used controlled substances which were obtained illegally or which were not obtained pursuant to a valid prescription
order or which were not taken following the direction of a licensed health care provider within the past 5 years?
	Yes No
8. Has any state, jurisdiction, province, or professional organization denied your application for credentials or professional
membership?	Yes No
9. Have you ever been named as a defendant or have been requested to respond as a defendant to a legal action involving
professional liability (malpractice) or had a professional liability claim paid in your behalf or paid such a claim yourself?
	Yes No
IF ANY OF THE ABOVE QUESTIONS HAVE BEEN ANSWERED "Yes," please explain circumstances and outcome
later on the form.

V. ACADEMIC REQUIREMENTS:

A. I am submitting official transcripts verifying having met the academic requirements as indicated (select one by initialing the

appropriate line.)

A graduate degree in mental health counseling or community counseling from a program accredited by the Council for

Accreditation of Counseling and Related Educational Programs (CACREP)

An acceptable graduate degree as determined by the Board which includes completion of a practicum and internship in

mental health counseling which was taken concurrently with the degree program and was supervised by a licensed mental

health professional as described in NRS 641A

Please print or type clearly giving an accurate record of your educational preparation below. YOU MUST COMPLETE ALL

INFORMATION FOR ALL SCHOOLS/COLLEGES/UNIVERSITIES/INSTITUTIONS ATTENDED AND DEGREES RECEIVED OR

YOUR APPLICATION WILL BE CONSIDERED INCOMPLETE. (You may attach additional sheets, if necessary.)

B. Undergraduate Education:

Name of School	Address	City	State	Zip
Title of Degree (in the original language)	Date Awarded	Major	Attendance From	To

C. Graduate Education in Marriage and Family Therapy:

Name of School	Address	City	State	Zip
Title of Degree (in the original language)	Date Awarded	Major	Attendance From	To

D. Other Graduate Study:

Name of School	Address	City	State	Zip
Title of Degree (in the original language)	Date Awarded	Major	Attendance From	To

E. Required Areas of Study:

1. Human Development, Including issues of Sexuality:	(minimum 1 course; 3 semester hours or 4 quarter hours)
Course Title (as it appears on Transcript)	Course Number:	Credit Hours:
2. Individual Counseling Theories:	(minimum 1 course; 3 semester hours or 4 quarter hours)
Course Title (as it appears on Transcript)	Course Number:	Credit Hours:
3. Individual Counseling Techniques and Practices:	(minimum 1 course; 3 semester hours or 4 quarter hours)
Course Title (as it appears on Transcript)	Course Number:	Credit Hours:
4. Lifestyle and Career Development:	(minimum 1 course; 3 semester hours or 4 quarter hours)
Course Title (as it appears on Transcript)	Course Number:	Credit Hours:
5. Group Dynamics Counseling and Consulting:	(minimum 1 course; 3 semester hours or 4 quarter hours)
Course Title (as it appears on Transcript)	Course Number:	Credit Hours:
6. Ethics and Professional Studies:	(minimum 1 course; 3 semester hours or 4 quarter hours)
Course Title (as it appears on Transcript)	Course Number:	Credit Hours:
7. Supervised Clinical Practice in CPC:	(minimum 3 courses; 9 semester hours or 12 quarter hours)
Course Title (as it appears on Transcript)	Course Number:	Credit Hours:
8. Diagnosis and Assessment:	(minimum 1 course; 3 semester hours or 4 quarter hours)
Course Title (as it appears on Transcript)	Course Number:	Credit Hours:
9. Social and Cultural Foundations:	(minimum 1 course; 3 semester hours or 4 quarter hours)
Course Title (as it appears on Transcript)	Course Number:	Credit Hours:
10. Research and Evaluation:	(minimum 1 course; 3 semester hours or 4 quarter hours)
Course Title (as it appears on Transcript)	Course Number:	Credit Hours:
11. Abuse of Alcohol or Controlled Substances:	(minimum 1 course; 3 semester hours or 4 quarter hours)
Course Title (as it appears on Transcript)	Course Number:	Credit Hours:

VI. SUPERVISED CLINICAL EXPERIENCE: (Already Licensed In Another State)

A. Requirements for licensure as an CPC:

1. Before an applicant is eligible for licensure as a marriage and family therapist, he must complete at least 3,000 hours of

experience in an approved internship. The requirements, found in NAC 641A.146, include:

a. At least 1,500 hours of direct face-to-face contact with clients in the practice of marriage and family therapy.

b. At least 300 hours of marriage and family therapy supervision by the approved primary or secondary supervisor of the intern.

See NAC 641A.146(3)(b)(1) and (2) for additional requirements.

c. At least 1,200 hours of work related to the practice of marriage and family therapy. See NRS 641A.146(3)(c)(1), (2), (3), (4)

and (5) for additional requirements.

An applicant who is currently licensed and in good standing as a marriage and family therapist in another state or jurisdiction may be

eligible for licensure, contingent upon meeting Nevada requirements. A Nevada License Verification Form* should be sent to each

licensing body to be returned directly to the Board office from each licensing body. The Board may accept, deny or grant partial credit

for requirements completed in another jurisdiction. Note: Supervision completed toward licensure as a clinician other than a marriage

and family therapist is not eligible to be used toward licensure as a licensed marriage and family therapist.

Checklist: If you are licensed in another state as a marriage and family therapist, please provide the following:

Copy of License

Verification of Licensure Form* (Have each licensing agency send this form to the Board office.)

Official Licensing Examination Score (Have the examining agency send your score to the Nevada Board office.)

Experience Verification Form* (Have documentation of supervision and/or supervised experience sent to the Board.)

* Experience Verification Form and License Verification Form found on the Licensing Information Page of the website: http://marriage.state.nv.us

Please list all professional licenses or certifications that you have held within the last 10 years.

Professional License Held/Experiration Date	Issuing Board / State	License Number	Issuing Date
	/
Professional License Held/Experiration Date	Issuing Board / State	License Number	Issuing Date
	/

VII. APPLICANT'S ATTESTATION:

A. I have reviewed the licensure eligibility requirements prior to submitting this application.	Yes No
B. I have completed the application materials and procedures honestly and in good faith.	Yes No
C. I understand that the members and staff of the Board are compelled by law to uphold, implement and enforce the
statutes and regulations as written.	Yes No
D. I understand that the Board has the statutory authority to refuse to grant licensure to, or may suspend, revoke, condition, limit,
qualify, or restrict the license of any individual that has knowingly made a false statement on a Nevada State form required for
licensure or licensure renewal.	Yes No
E. I have read and am familiar with the statutes and regulations governing the practice of marriage and family therapy in Nevada.
	Yes No
F. I understand that once the Board receives my application I am bound by, and will abide by, the statutes and regulations
governing the practice of marriage and family therapy in Nevada.	Yes No

VIII. CHILD SUPPORT STATEMENT

Nevada state law requires that all applicants for issuance of a license be required to provide the following information concerning

the support of a child. As part of this application, your responses to these questions are given under oath and any response given

hereto which is false, fraudulent, misleading, inaccurate or incomplete, will result in your application being denied. You must mark

one of the following responses. Failure to indicate which provision applies will result in your application being denied.

I am not subject to a court order for the support of a child.

I am subject to a court order for the support of one or more children and am in compliance with an order or am in compliance with

a plan approved by the district attorney or other public agency enforcing an order for the repayment of the amount owed pursuant

to the order.

I am subject to a court order for the support of one or more children and am NOT in compliance with an order or a plan approved

by the district attorney or other public agency enforcing the order for the repayment of the amount owed pursuant to the order.

IX. AFFIDAVIT:

I agree to allow the Board of Examiners for Marriage & Family Therapists and Clinical Professional Counselors ("Board") to

communicate with any person in connection with this application. I will hold the Board, its members, officers, and agents free from

any liability or complaint by reason of any action any of them may take in connection with the Board's investigation of my

professional training, experience, or personal and professional background.

The undersigned hereby applies for a license, under the laws and regulations governing marriage and family therapists and certifies

under penalty of perjury that all statements contained herein are true and correct to the best of his/her knowledge and belief; that

he/she is the person named in the credentials submitted, and the same were procured in the regular course of instruction and

examination, without fraud or misrepresentation; and with full knowledge that all statements made in this application may be subject to

investigation, including a check of fingerprints, police records, and former employers. I understand that if any of my responses on this

application are false, fraudulent, misleading, inaccurate or incomplete, my application will be denied.

Signature:__________________________________________ Date:______________________________________

X. FINGERPRINTING AND BACKGROUND CHECK:

Using black ink, fill in the boxes on the top half of the cards (SSN, sex, race, height, etc.) and sign where indicated. It is recommended

that you go to a police precinct to use their fingerprinting department. Have the Officer note any scars on the fingerprint area or any

irregularities, such as missing digit, etc. You do not have to be fingerprinted in Nevada. All encouraged to start this process immediately

as results may take 6-12 weeks. Follow the Background Check Procedure as written in the Background Check Procedure Letter.

First Name	Last Name	Experation Date MM/YYYY
		/
Billing Address	City	State (XX)	Zip (XXXXX-XXXX)
Account Number (no dashes)
By entering my credit card and clicking "Submit" I authorize the charge to my card of the amount due for my license application.