Supervised work experience documentation form lcdc 2008-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Counselor Intern Information. Fill in your name, social security number, and date of birth. Ensure accuracy as this information is crucial for processing.
3. Next, provide details about your CTI Site Information. Include the headquarters name, site name, telephone number, and complete address.
4. In the Training Information section, input the dates of service and job title during that timeframe. Remember to attach a copy of your job description for verification.
5. Complete the Qualified Credentialed Counselor Information by indicating if direct supervision was provided. If not, include the supervisor's name and license number.
6. Finally, sign and date the form at the bottom to affirm that all information is true and accurate before submitting it to the Texas Department of State Health Services.

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