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Supervised experience documentation form 2026

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The document is a Supervised Work Experience Documentation Form for Counselor Interns (CIs) to report their job titles, training information, and supervision details. It requires submission to the Texas Health & Human Services for licensing purposes, including verification of hours worked and compliance with regulations. The form must be completed by both the intern and the Qualified Credentialed Counselor (QCC), ensuring accurate reporting of the intern's experience and qualifications.

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Click ‘Get Form’ to open the supervised experience documentation form in the editor.
Begin by filling out the 'Counselor Intern Information' section. Enter your name, social security number, and mailing address clearly. Ensure all fields are completed accurately.
In the 'CTI Site Information' section, provide details about your CTI headquarters and site name, including contact information and address.
Next, complete the 'Training Information' section. Input the dates of service, hours worked per week, job title during this timeframe, and total clock hours in KSA domains.
For the 'Qualified Credentialed Counselor Information', indicate if you provided direct supervision to the intern. If not, include the supervisor's details.
Finally, ensure that both you and the CTI coordinator sign and date the form before submission. Review all entries for accuracy.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (41 Votes)
2011	4 Satisfied (31 Votes)
2008	4.1 Satisfied (63 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What counts as direct hours for LPC?

DIRECT: A direct client contact hour is a service that the student provides to the client face-to- face, where the student and the client are both in the same room, for at least most of the hour.

How do I upgrade to the LPC in Texas?

All applicants for upgrade to full LPC must: submit a complete application (fee was imbedded in the Associate fee) complete the Texas Jurisprudence Examination submit a self-query report from the National Practitioner Data Bank submit Supervised Experience Documentation form(s) -Out of State: Licensed

How many hours of supervision for LPC in Texas?

(i) An LPC Associate must continue to be supervised after completion of the 3,000 hours of supervised experience and until the LPC Associate receives his or her LPC license. Supervision is complete upon the LPC Associate receiving the LPC license.

What are the requirements for LPC in Texas?

Basic Licensure Requirements for LPC License Graduate degree in counseling (or related field) from an accredited university/college, which includes at least 300 hours of supervised practicum. Pass National Counseling Exam or National Clinical Mental Health Counseling Exam. Complete LPC Jurisprudence Exam.

How many Interns can an LPC supervise in Texas?

(g) The LPC Intern must receive direct supervision consisting of a minimum of four hours per month of face to face or live Internet webcam supervision in individual (up to two Interns) or group (three or more) settings for each week the intern is engaged in counseling.

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