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FORMS
 

License Application and Renewal Forms

Mail application forms and application fee to the Board's office: 
Board of Licensed Professional Counselors & Therapists
3218 Pringle Road SE, Suite 120
Salem, OR   97302-6312 
 
All application forms, fees and background check information must be submitted to the Board before application is considered complete.
 
Application Forms
Renewal Forms 
Please contact Board office if 2016 form is required.
(Scroll down for other forms)

Which Application Forms Do I Need?
If you are going to register as an intern to gain hours toward licensure, submit the following to the Board:
  • Form 1 Application 
  • Form 2A  Degree Program Direct Client Contact Hours 
  • Form 5 Professional Disclosure Statement
  • Form 6A Graduate Degree information ** (completed by your college)
  • Form 7 Intern Supervised Clinical Experience Plan
  • Criminal background check/fingerprints (Fingerprint Instructions)
  • Your college transcript mailed directly from your college to the Board Office
  • Application fee of $215
All forms and fees must be completed and submitted to the Board before you can begin accruing supervised hours toward licensure. 
 
If you apply by the direct method, submit the following to the Board:
  • Form 1 Application
  • Form 2 Post-Degree Supervised Clinical Experience   >> See note below.
  • Form 2A Degree Program Direct Client Contact Hours 
  • Form 3 Exam verification (if appropriate)
  • Form 5 Professional Disclosure Statement
  • Your college transcript mailed directly from your college to the Board Office
  • Criminal background check/fingerprints (Fingerprint Instructions) 
  • Form 6A Graduate Degree information  **
  • Application fee of $215
If you apply by the reciprocity method, submit the following to the Board:
  • Form 1 Application
  • Form 4 Verification of License from another state
  • Form 5 Professional Disclosure Statement
  • Your college transcript mailed directly from your college to the Board Office
  • Criminal background check/fingerprints (Fingerprint instructions)
  • Form 6A Graduate Degree information  **
  • Application fee of $215
If you are unsure which forms to submit, please contact the Board office for guidance. 
 
>> Clinical experience reported on Form 2 must have been earned in Oregon before 2002 or in another state.
 
** Form 6a is not needed if you graduated from a university or college that was accredited (at the time you graduated) by CACREP, CORE, or COAMFTE.
 

Other Forms