Appraisal Counseling Consulting referral research11 upervisorx2019s conclusions and recommendations This Jersey supervisor applicantx2019s The Yes The clientx2019s Yes The Yes ID: 440210
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Niw Nivwiy Sf�gi sf xli Exxsvriy Girivep Division of Consumer Affairs State Board of Marriage and Family Therapy Examiners 124 Halsey Street, 6th Floor, P.O. Box 45044 Telephone Telephone Quali�ed supervisor: N.J.A.C . 13:34-10.2 and 13.1(a) (Check all that apply.) (For Licensed Professional Counselors Only) (Attach of�cial veri�cation for area(s) you checked.) ACS(NBCC-Issued) ThreeSupervision Do Yes If“Yes,” Psychiatrist Marriage Nehabilitation Psychologist Professional ClinicalWorker Year License Yes If“Yes,” CONTACT THE ISSUING LICENSING BOAND TO OBTAIN AN OFFICIAL LETTEN OF GOOD STANDING. Psychiatrist Marriage ClinicalWorker Physician Nehabilitation Other: Professional Psychologist Year License State for: Licensed Licensed clearly. For Of�cial Use Only Yes 3. Graduate Mafor: 4. Is Yes If“Yes,”pleaseexplainonseparatesheetofpaper. N.J.A.C 13:34-13.1(Examples:currentandformerclients, currentemployers(employeesmaynotsuperviseemployers),relativesofthesupervisor,relativesofcurrentclients, current The information requested below concerns the setting in which the applicant received his or her supervised experience. Tax status: for-pro�t not-for-pro� City Telephone 1. Applicant’s 2. Inclusive Year”hours/year, 3. Total supervision: 4. Average 5. Average 6. Iapply. (See I Iapplicant’s Iapplicant’s Iapplicant’s 7. Iapply. (See I I 8. Iapply. (See I Iapplicant’s affectingapplicant’s Ioffered Iofferedapplicant’saffect Ioffered Other Did Yes Services provided by supervisee: Clinically Conduct Plan, Counseling procedures implemented by supervisee: Appraisal Counseling Consulting Neferral Nesearch 11. Supervisor’s conclusions and recommendations ThisapplicantisseekingtobecomeLicensedProfessionalCounselororLicensedNehabilitationCounselorinNewJersey. supervisor.applicant’s The Yes Theclient’s Yes Yes Yes Theone’s situation. Yes Theeffectively Yes Theeffectively Yes Thebehavior. Yes On a separate sheet of paper, please assess the applicant’s current state of preparedness for licensure. Also, please make a recommendation regarding the applicant’s further professional development. Your recommendations are an important element in the Committee’s overall evaluation of the applicant’s quali�cations for licensure. (Please explain in details why in the comment section below.) 4 4