Revised -10/07/2016 REGISTRY OF CERTIFIED PROFESSIONAL COUNSELOR SUPERVISORS, CPCS Applicants Name (Please Print) Non-Member RECERTIFICATION Application Fee $75.00, (Fees can be paid online, http://www.lpcaga.org/join-us (Click on the Membership tab)) OR Current Clinical Member of LPCA, $75 fee included in Clinical Membership Clinical Members Late Fee -- $25.00 (any application after 10/01/16) pay online My GA LPC license is Current , my license #LPC_ _ _ _ _ _ Compliance with the CODE OF ETHICS. My license in Georgia or another state or province, has NEVER been subject to terms of probation, suspension, or revocation. The information on the Supervisor Directory is correct http://www.lpcaga.org/Supervisor-Directory CHANGE the information on the Supervisor Page to: RENEWAL OPTIONS- Check one of the three options or if you are NOT recertifying: Option A: 12 CEs in Clinical Supervision workshops. MUST include copies of the CEs. Must have some variance of the word "supervision" in the title and at least 3 hours must be in the Ethics of Supervision. Option B: Attended at least 6 CE Hours of Clinical Supervision workshops and Presented up to 6 hours of Clinical Supervision Workshop(s). MUST include copies of the CEs. At least 3 CE hours must be in the Ethics of Supervision. Option C: Initial CPCS certification was granted after October 1 of the previous odd- numbered year. CEs from Initial Application may be used so as to not create an undue financial hardship. Click Submit at the top right of this document or EMail, Fax, or Scan all completed forms (and payment) to: [email protected] LPCA CPCS PHONE: 770-449-4547 3091 Governors Lake Dr NW, STE 570 FAX: 404-370-0006 NORCROSS, GA 30071 EMAIL: [email protected] CPCS RECERTIFICATION When payment is completed List your Order #___________ Or make check payable to LPCA: CK#________ Check Box if You are NOT recertifying. Make sure your marketing does not still list the CPCS Check Box if I need more Time, EXTENSION REQUEST
CPCS RECERTIFICATION - Wild Apricot · 2016-10-24 · LPCA CPCS PHONE: 770-449-4547 3091 Governors Lake Dr NW, STE 570 FAX: 404-370-0006 NORCROSS, GA 30071 EMAIL: [email protected]
Aug 15, 2020
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Revised -10/07/2016
REGISTRY OF CERTIFIED PROFESSIONAL COUNSELOR SUPERVISORS, CPCS
Applicants Name (Please Print)
Non-Member RECERTIFICATION Application Fee $75.00,(Fees can be paid online, http://www.lpcaga.org/join-us (Click on the Membership tab))
OR
Current Clinical Member of LPCA, $75 fee included in Clinical MembershipClinical Members Late Fee -- $25.00 (any application after 10/01/16) pay online
My GA LPC license is Current , my license #LPC_ _ _ _ _ _
Compliance with the CODE OF ETHICS.My license in Georgia or another state or province, has NEVER been subject to terms of probation, suspension, or revocation.
The information on the Supervisor Directory is correct http://www.lpcaga.org/Supervisor-Directory
CHANGE the information on the Supervisor Page to:
RENEWAL OPTIONS- Check one of the three options or if you are NOT recertifying:
Option A: 12 CEs in Clinical Supervision workshops. MUST include copies of the CEs.Must have some variance of the word "supervision" in the title and at least 3 hours must be in the Ethics of Supervision.
Option B: Attended at least 6 CE Hours of Clinical Supervision workshops and Presented upto 6 hours of Clinical Supervision Workshop(s). MUST include copies of the CEs.At least 3 CE hours must be in the Ethics of Supervision.
Option C: Initial CPCS certification was granted after October 1 of the previous odd-numbered year. CEs from Initial Application may be used so as to not create an unduefinancial hardship.
Click Submit at the top right of this document or EMail, Fax, or Scan all completed forms(and payment) to: [email protected]
LPCA CPCS PHONE: 770-449-45473091 Governors Lake Dr NW, STE 570 FAX: 404-370-0006NORCROSS, GA 30071 EMAIL: [email protected]
CPCS RECERTIFICATION
When payment is completed List your Order #___________ Or make check payable to LPCA: CK#________
Check Box if You are NOT recertifying. Make sure your marketing does not still list the CPCS
Check Box if I need more Time, EXTENSION REQUEST
Revised -- 08/31/2016
Page 2
Include copies of your CE Certificates
Date(s) ofworkshop orConference,
etc.
Course/Activity-Title of Workshop or Training
If it does not include a "variance" of the wordSupervision- do not include it.
Provider Organizationand Instructor Name and
Credentials(required)
DocumentationRequired- CE Approval
#(i.e. Certificate 0000)
Was this workshopElectronically
Delivered?
# of ContactHours
Or CE's
Example2- 12- 2015 Ex. Ethical Matters in Clinical Supervision Ex. North GA Division LPCA
Instructor- Dr. John Smith, LPC Ex. Certificate LPCA #0000-00 YES or NO Ex. 5 hours
Total: ____________
Requirements
Workshops must be about CLINICAL supervision NOT employee supervision, AAMFT supervision, or addiction supervision.
At least 3 CEs must be in the Ethics of Supervision.
Only 1/3 of the CEs may be online (Electronically Delivered) workshops, but none of the ethics can be online.
Must include Copies of the CE Certificates with the renewal unless using Option C.
CPCS SUPERVISION TRAINING – Continuing Education Obtained
Check Box
Check Box
Check Box
Check Box
DID YOU INCLUDE COPIES OF YOUR CES?
Revised -- 08/31/2016Page 3
Name of Presenter :Date(s)
Ofworkshop
Title of WorkshopMust include a "variation" of the word Supervision
LPCA/NBCCCE #
(required)Location
#of
Attendees
CE hours&
Category**
2/09/16 Theoretical Models of Supervision 1234-15 Marietta Civic Center 123 6 - F
Requirements
Workshops must be about CLINICAL supervision NOT employee supervision, AAMFT supervision, or addiction supervision.** CPCS CE / Course Categories
(E) Ethics and Legal Issues in Supervision
(F) Foundations of Supervision(M) Methods in Supervision
(S) Specialized / Advanced Techniques in Supervision
I attest that the above information is true and accurate to the best of my ability:
Name: Date: Signature
CE Supervision Workshops Presented / Graduate Supervision Courses Taught
Check Box
Check Box
Check Box
Check Box
Must include Copies of the CE Certificates with the renewal unless using Option C
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