If you are a human and are seeing this field, please leave it blank. VERIFICATION OF STATE PROFESSIONAL COUNSELOR LICENSURE FORM Applicant's Name Note: This form is not to be used to document State School Counselor Certification. Only submit this form if you hold a State Professional Counselor License, Social Worker License, or Psychologist License. Individuals holding State License in these areas must indicate coursework, and/or post-graduate training, in marriage and family counseling/therapy and post-graduate supervised experience. I have applied to the National Credentialing Academy for Certified Family Therapists and am required to provide verification of my license/registration granted by your board. Please complete the information requested below and mail the form directly to NCA at the address below. My application cannot be processed until this form is received. Date 1. Does the applicant hold a current state license? State Professional Counselor LicenseState Social Worker LicenseState Psychologist License Date of Membership Exp. Date 2. Is the applicant currently in good standing? YESNO If NO, please comment in box below. FORM WAS COMPLETED BY: NOTE: Applicant may submit photocopy of current professional counselor license in lieu of this form.