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Professional×Disclosure×Statement, ×Counseling×agreement, ×and×Consent×for×Treatment×Form Shannon Delay, Med, LPC, LUCAS, MAC, NBC, CAC
5970 Fairview Road, Suite 414
Charlotte, NC 28210
980.338.4155
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How to fill out nc lpc prof disclosure
How to fill out nc lpc prof disclosure
01
To fill out the NC LPC Prof Disclosure form, follow these steps:
02
Begin by accessing the NC LPC Prof Disclosure form either online or in a printable format.
03
Read through the instructions and familiarize yourself with the requirements.
04
Provide your personal information such as your name, contact details, and LPC license number.
05
Include your educational background, specifying the degrees or certifications you have obtained.
06
List any relevant professional experience you have in the field.
07
Disclose any past or pending legal actions, complaints, or disciplinary actions against you.
08
Provide information regarding your current practice, including your business name, address, and contact information.
09
Indicate any specializations or populations you primarily work with.
10
Sign and date the form to certify the accuracy of the information provided.
11
Ensure you have completed all required fields and review the form for any errors or omissions before submitting.
12
Submit the completed NC LPC Prof Disclosure form to the appropriate authority or organization as instructed.
Who needs nc lpc prof disclosure?
01
The NC LPC Prof Disclosure is required for licensed professional counselors (LPC) practicing in North Carolina.
02
This form is necessary for both new applicants seeking a license and current LPCs maintaining their licensure.
03
It ensures transparency and provides clients or potential clients with important information about the counselor's background, qualifications, and any potential conflicts of interest or disciplinary actions.
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