Oregon Board of Licensed Professional Counselors and Therapists - oregon 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name, agency name, location address, mailing address, city/state/zip, telephone number, and email in the designated fields.
3. In section A, list the names of registered interns or supervisees you have worked with over the last five years along with their supervision dates and credentials (LPC or LMFT).
4. For section B, provide details about your national supervisor credential including the certification title, issuing organization, certification number, original issue date, and expiration date.
5. In section C, document your supervision training by listing coursework or workshops completed along with the title of each class, sponsor of the program, date taken, and clock hours.
6. Review section D carefully to understand your responsibilities as a supervisor. Ensure compliance with all outlined duties.
7. Finally, sign and date the certification section at the bottom before submitting your completed form to the Board's address provided.

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