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10 24 12- #464 Doc of Clinical Experience Gained under Train Lic - Supvr Aff of Applicant's Competen 2026
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Definition & Meaning
The "10 24 12- #464 Doc of Clinical Experience Gained under Train Lic - Supvr Aff of Applicant's Competen" is a documentation form that verifies clinical experience for professionals seeking licensure in fields such as marriage and family therapy, professional counseling, and social work. This form serves as a Supervisor's Affidavit that confirms an applicant's completed clinical hours and competencies under a training license. It is a crucial component for demonstrating that the applicant has met the necessary practical experience requirements mandated by the licensing board.
- Purpose: To verify clinical experience gained under supervision.
- Applicable Professions: Marriage and family therapists, professional counselors, and social workers.
- Requirement: Essential for licensure application in various states, including adherence to state-specific codes like the Wisconsin Administrative Code.
How to Use the Form
Utilizing the "10 24 12- #464 Doc" involves several careful steps to ensure proper completion and submission. The form is primarily used by supervisors to document and attest to an applicant’s clinical competencies and experience gained under a training license.
- Document Preparation: Gather all relevant clinical experience records to aid in accurate reporting.
- Supervisor’s Role: The applicant’s supervisor must fill out sections related to the applicant's experience and verify hours and competencies.
- Form Completion: Ensure every section is accurately completed, including personal details, supervised hours, and specific competencies achieved.
- Review and Validation: Double-check the form for completeness and accuracy before submission. Both the supervisor and the applicant should conduct a thorough review.
Steps to Complete the Form
Outlined below are the steps to successfully complete the "10 24 12- #464 Doc":
- Personal Information: Begin with filling in personal details like name, address, and contact information of the applicant.
- Supervisor’s Information: Input details about the supervisor, including their name, license number, and contact information.
- Clinical Experience: Document the total hours of clinical practice, specifying the nature of practice, such as client contact hours and any special areas of competency.
- Competency Assessment: The supervisor completes an assessment section that details the applicant's performance and areas of skills.
- Signatures: Secure signatures from both the supervisor and applicant to complete the form authentically.
- Documentation: Attach any required supporting documents that validate the experience stated, such as session logs and evaluations.
Key Elements of the Form
Understanding the critical components of this form is essential for accurate completion and to fulfill the necessary requirements.
- Applicant Details: Information about the applicant, including credential specifics and professional experience background.
- Supplied Experience Hours: Detailed recording of the hours and types of client contact performed.
- Competency Confirmation: Includes evaluation of specific skill sets and the applicant’s readiness to manage client cases independently.
- Signature Section: Affirmation of truthfulness and accuracy by the overseeing supervisor and the applicant.
Legal Use of the Form
This form is legally binding and ensures that the declared competencies and experience align with state regulations. It substantiates the qualification of the practitioner to undertake independent professional roles after licensing.
- Compliance: Necessitates adherence to legal standards set by state licensing boards.
- Verification: Acts as a validated document for the licensure approval process.
- Regulatory Alignment: Ensures that the licensed professional meets all state-mandated clinical experience requirements.
State-Specific Rules
Depending on the state, there may be specific regulations and code of conduct pertaining to the use of this form. The following aspects highlight some variations:
- Wisconsin Requirements: As an example, the Wisconsin Administrative Code dictates the use of the form for documenting 3,000 hours of supervised practice, including 1,000 hours of client contact.
- Different Approaches: Each state may have additional or varied requirements for acceptable supervision and client hour counts.
Important Terms Related to the Form
Understanding specific vocabulary related to the form can aid in accurate completion and comprehension.
- Clinical Experience: Refers to practical, hands-on work performed under supervision, essential for licensure.
- Training License: A provisional licensure allowing practice under supervision before full licensure.
- Supervisor's Affidavit: A sworn confirmation by a licensed supervisor that the applicant has fulfilled the necessary clinical experience.
Who Typically Uses the Form
This form is specifically used by applicants in regulated health professions who need to document clinical experience for licensure.
- Professionals: Primarily utilized by marriage and family therapists, counselors, and social workers.
- Supervisors: Licensed professionals verifying the applicant’s training and readiness.
- Licensing Boards: Entities evaluating the form as part of the licensing process.
In summary, the "10 24 12- #464 Doc of Clinical Experience Gained under Train Lic - Supvr Aff of Applicant's Competen" is a critical document for professionals transitioning from training licenses to full licensure, requiring diligent completion and understanding of both general and state-specific requirements.
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How do I become a LPC supervisor in Wisconsin?
Wisconsin Requirements for Clinical Supervisors Wisconsin LPC Doctoral degree in professional counseling or an LPC who has practiced for at least 5 years, or a licensed psychologist or psychiatrist, or a supervisor who is approved in advance by the board.
How many supervision hours for LPC in Wisconsin?
o Note: The 3,000 post-graduate supervised hours can now be completed in less than two years. Complete and submit Professional Counselor Application including required documentation and fees. o An applicant for permanent licensure may apply for a temporary license at the same time.
What is the difference between LPC and LPCC in Wisconsin?
Both of these licenses permit the practice of counseling, but the LPCC will often have more of a specific focus on mental health; the LPC is broader and may include career counseling, rehabilitation counseling, marriage and family therapists, and other areas not directly related to mental health.
How much does a LPC make in Wisconsin?
Licensed Professional Counselor Salary in Wisconsin Annual SalaryHourly Wage Top Earners $101,944 $49 75th Percentile $80,700 $39 Average $65,983 $32 25th Percentile $59,000 $28
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