Get Virginia Quarterly Evaluation 2019-2024

Dhp.virginia.gov/counseling QUARTERLY EVALUATION FOR LPC LICENSURE Section 115-20-52-D-3 of the Virginia LPC regulations requires that the applicant s supervisor provide quarterly evaluations to the resident. This form must be signed and dated by the supervisor. This form is to be completed by the supervisor each quarter and provided to the resident to be held in their possession until they are ready to submit their licensure application. Name of Applicant Last First Middle Applicant s Email Address SUPERVISOR S EVALUATION Supervisor s Name Last First License Number License Type Business Name and Address of Residency Work Site Where Clinical Hours Were Obtained ONE LOCATION ONLY Dates of supervision From mm/dd/yy All Columns Must Be Completed To mm/dd/yy Hours per week Hours are duplicated on another supervisor s quarterly form Total hours Total hours of supervised residency face-to-face client contact hour ancillary hours How many Face-to-face Client Contact hours did the resident provide Yes No How many Individual Supervision hours did the resident receive How many Group Supervision hours did the resident receive If applicable Total number of face-to-face client contact with Couples and Families or both. COMMONWEALTH OF VIRGINIA Department of Health Professions Board of Counseling Perimeter Center 9960 Mayland Drive Suite 300 Henrico VA 23233-1463 Email coun dhp*virginia*gov Phone 804 367-4610 Fax 804 527-4435 Website www. substance abuse treatment services. These areas are outlined in Section 18 VAC 115-20-52 of the LPC Regulations. The resident must have supervised residency in the role of a professional counselor working with various populations clinical problems and theoretical approaches in the below areas. Did the applicant provide assessment and diagnosis using psychotherapy techniques while under your direct supervision while under your direct supervision under your direct supervision Do you have any concerns about the competency of the resident If yes explain on separate page. substance abuse treatment services. These areas are outlined in Section 18 VAC 115-20-52 of the LPC Regulations. The resident must have supervised residency in the role of a professional counselor working with various populations clinical problems and theoretical approaches in the below areas. The resident must have supervised residency in the role of a professional counselor working with various populations clinical problems and theoretical approaches in the below areas. Did the applicant provide assessment and diagnosis using psychotherapy techniques while under your direct supervision while under your direct supervision under your direct supervision Do you have any concerns about the competency of the resident If yes explain on separate page. substance abuse treatment services. These areas are outlined in Section 18 VAC 115-20-52 of the LPC Regulations. The resident must have supervised residency in the role of a professional counselor working with various populations clinical problems and theoretical approaches in the below areas. Did the applicant provide assessment and diagnosis using psychotherapy techniques while under your direct supervision while under your direct supervision under your direct supervision Do you have any concerns about the competency of the resident If yes explain on separate page.