LPC License Renewal Form

LPC License Renewal Form

Licensee Name:   License Number:

Mailing Address:

WHEREAS

WHEREAS, Licensee is a duly licensed Licensed Professional Counselor in good standing and seeks renewal of the license identified above; and

WHEREAS, the Licensing Authority administers licensure renewal processes, collects renewal fees, and enforces continuing education and disciplinary requirements; and

WHEREAS, Licensee agrees to comply with renewal requirements, attest to the accuracy of submitted information, and accept the terms and conditions set forth in this renewal form.

Scope of Work / Practice

Describe the primary settings and scope of practice to be covered under the renewed license (clients served, modalities, supervision responsibilities):

Continuing Education

Total continuing education hours completed for renewal period:

Provide a brief summary of course titles and dates (attach additional documentation if required):

Payment Terms

Renewal Fee Amount:

Payment acknowledgement: I understand fees are non-refundable except as required by law.

Term and Termination

Renewal Effective Date:   Renewal Expiration Date:

Notice Period for Termination by Licensing Authority (if applicable):

Termination for cause includes but is not limited to fraud in application, failure to maintain required CE, conviction of offenses materially related to the practice of counseling, or violation of professional standards. Upon termination, practice privileges revert as required by statute and any outstanding fees or sanctions become due.

Declarations

Have you been the subject of any disciplinary action by a licensing board since your last renewal? No Yes

Have you been convicted of a felony or any offense substantially related to the practice of counseling since your last renewal? No Yes

Confidentiality

All non-public information provided in connection with this renewal, including continuing education documentation and disciplinary explanations, will be treated as confidential administrative records to the extent permitted by law. The Licensing Authority may disclose information as required for investigations, public protection, or pursuant to legal process. Licensee acknowledges that confidentiality does not extend to disclosures mandated by statute or regulation.

Governing Law

This renewal form and any dispute arising out of or related to it shall be governed by the substantive laws of the state in which the license is principally held, without regard to conflict-of-law principles. Licensee consents to the jurisdiction of the appropriate courts in that state for enforcement or dispute resolution.

Entire Agreement

This form, together with any attachments submitted in support of renewal, constitutes the entire agreement between Licensee and the Licensing Authority with respect to the subject matter hereof. Any prior agreements, representations, or understandings, whether written or oral, are superseded by this renewal form. Amendments must be in writing and signed by an authorized representative of the Licensing Authority.

Attestation and Certification

By signing below, Licensee certifies under penalty of perjury that the information provided on this form is true, complete, and accurate to the best of Licensee’s knowledge. Licensee acknowledges that falsification or omission may subject the license to discipline, denial, suspension, or revocation and may carry civil or criminal penalties.

Certification: I hereby certify the statements above and the attached documentation are true and correct.

Sign Now