Licensure Education Assistance Program

Licensure Education Assistance Program

MASTER LEVEL APPLICATION
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Social Security Number
Date of Birth

MonthDayYear
Date
Will any documentation submitted in connection with this application be received in a name other than the name under which you are applying?
If Yes, please list the other name or names below. (Submit a copy of the legal document evidencing the name change (i.e., marriage certificate, divorced decree or court order)

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Which LEAP application are you completing?
Accredited School Where Degree Obtained:
Address of School

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Of Graduation

MonthDayYear
Date
COAMFTE Approved Post-Graduate Program: If you are not applying for MFT, put N/A
Do you hold or have you ever held, a license, certificate, permit,registration or other authorization to practice a profession or occupation in any state or jurisdiction?
If yes, please list all professions and states where you have been licensed and request a letter of good standing be sent from each state board to the Pennsylvania Board.
Have you had disciplinary action taken against a professional or occupational license, certificate, permit, registration or other authorization to practice a profession or occupation issues to you in any state or jurisdiction or have you agreed to voluntary surrender in lieu of discipline?
Do you currently have any disciplinary charges pending against your professional or occupational license certificate, permit or registration in any state of jurisdiction?
Have you withdrawn an application for a professional or occupational license, certificate, permit or registration, had an application denied or refused, or for disciplinary reasons agreed not to apply or reapply for a professional or occupational license, certificate, permit or registration in any state or jurisdiction?
Have you been convicted (found guilty, pled guilty or plead nolo contendere), received probation without verdict or accelerated rehabilitation disposition (ARD), as to any criminal charges, felony or misdemeanor, including any drug law violations? Note: You are not required to disclose any ARD or other criminal matter that has been expunged by order of a court.
Do you currently have any criminal charges pending and unresolved in any state or jurisdiction?
Do you have any mental or physical condition that would prevent you from practicing counseling with reasonable skill?
Have you ever violated standards or professional practice or conduct?
Do you currently engage in or have you ever engaged in the intemperate or habitual use or abuse of alcohol or narcotics, hallucinogenic or other drugs or substances that may impair judgment or coordination?
Have you ever had provider privileges denied, revoked, suspended, or restricted by a Medical Assistance agency, Medicare, third party payor or another authority?
Have you ever had practice privileges denied revoked, suspended or restricted by a hospital or any health care facility?
Have you ever been charged by a hospital, university, or research facility with violating research protocols, falsifying research, or engaging in other research misconduct?
IF YOU HAVE ANSWERED “YES” TO ANY QUESTIONS FROM 2 THROUGH 14, PLEASE ATTACH AN8 1⁄2 X 11 SHEET OF PAPER GIVING FULL DETAILS. INCLUDE COURTHOUSE CERTIFIED COPIES OF ANY DOCUMENTS EXPLAINING THE SITUATION, IF APPLICABLE.

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Employment Information
Place of Employment
Address of Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Employer
Please enter a valid phone number.Format: (000) 000-0000.
Name of Current Supervisor

First NameLast Name
Email of Supervisor
example@example.com
Phone Number of Supervisor
Please enter a valid phone number.Format: (000) 000-0000.
Clinical Information ONLY REQUIRED FOR MFT, LPC AND LCSW. LSW put 0
Type of License you are applying for:
Number of direct clinical hours obtained (required for MFT, LPC, LCSW ONLY. LSW type 0)
Total number of post master's supervised clinical hours (required for MFT, LPC, LCSW ONLY. LSW type 0)
Current hours of individual supervision (required for MFT, LPC, LCSW ONLY. LSW type 0)
Current hours of group supervision (required for MFT, LPC, LCSW ONLY. LSW type 0)
Total hours of supervision (required for MFT, LPC, LCSW ONLY. LSW type 0)
Supervisor Information

Name of your Supervisor, dates, and hours of supervision hours they provided for you:
Do you currently have clinical supervision hours? (LSW click N/A)
If yes, how many clinical supervised hour you have obtain?
Supervisor Name

First NameLast Name
Supervisor Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Supervisor Email Address
example@example.com
Date of Supervisor (Start)

MonthDayYear
Date
Date of Supervisor (End)

MonthDayYear
Date
Direct Client Contact Hours (Individual)
Direct Client Contact Hours (Group)
Supervision Hours
Supervisor Name

First NameLast Name
Supervisor Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Supervision (Start)

MonthDayYear
Date
Date of Supervision (End)

MonthDayYear
Date
Direct Client Contact Hours (Individual)
Direct Client Contact Hours (Group)
Supervision Hours
Total Number of Hours Received
References are required for all applicants (MFT, LPC, LSW, LCSW)
Professional Reference 1

First NameLast Name
Professional Reference 1 Email
example@example.com
Professional Reference 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Professional Reference 2

First NameLast Name
Professional Reference 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Professional Reference 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Availability

BBC LEAP© is an intensive program to prepare you for licensure. Complete the following chart with your availability. These times will include a minimum of ten (10) community service hours per week (counseling, trainings, workshops, community outreach. Etc.), study group is a minimum of 3 hours per week, individual/group supervision is a minimum of 1 hour per week.
Client Contact Hours: Total of 10 hours per week - Group & Individual Therapy (Only REQUIRED FOR MFT and LPC)
Individual Supervision: 1 Hour per week (Only REQUIRED FOR MFT and LPC)
Study Group: Total of 3 hours per week
Are you available 6pm-9pm during the week?
Documentation

The following information must be submitted along with your completed application for review:
Copy of Master's Degree

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Transcripts

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Do you have Child Abuse Clearance (Not required until accepted)
Child Abuse Clearance

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PA State Criminal Background Check

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Do you have PA State Criminal Background Check (Not required until accepted)
FBI Clearance (If you have NOT lived in PA for the past 5 years)

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Do you have General Liability Insurance (Not required until accepted)
General Liability Insurance

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Resume/ Curriculum Vitae

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VERIFICATION

I verify that that this application is in the original format as supplied by the Black Brain Campaign Licensure Education Assistance Program© and has not been altered or otherwise modified in any way. I verify that the statements in this application are true and correct to the best of my knowledge, information and belief. I understand that false statements that are made may result in suspension, revocation or denial of this licensure program.
Signature
Should be Empty:

Licensure Education Assistance Program

Employment Information

Clinical Information ONLY REQUIRED FOR MFT, LPC AND LCSW. LSW put 0

Supervisor Information

References are required for all applicants (MFT, LPC, LSW, LCSW)

Availability

Study Group: Total of 3 hours per week

Documentation

VERIFICATION