Verification of Post-master's Experience and Supervision Form

Applicant’s Name:
NBCC ID Number:
This form is for NCC applicants from non-CACREP-accredited programs to document 3,000 hours of
post-master’s counseling work experience and 100 hours of direct supervision over a 24-month period.
Please duplicate this form as needed to document multiple supervisors or work experience sites.
SECTION 1
I am a state-licensed counselor. (Attach a copy of your license and online verification and skip to section 4.)
I hold a doctoral degree in counseling. (Include an official sealed transcript documenting the conferred doctoral
degree and skip to section 4.)
I am NOT a state-licensed counselor and do not have a doctoral degree in counseling. (Submit this form to a
qualified counseling supervisor and ask them to complete sections 2 and 3. Once returned, complete section 4
and mail it to NBCC.)
SECTION 2- Supervision
I am applying to the National Board for Certified Counselors, Inc. for the National Certified Counselor (NCC) credential. I am
required to provide documentation of a total of 24 months of postgraduate professional counseling experience, including at
least 3,000 hours of counseling work experience and 100 hours of direct clinical supervision. Please complete the information
below and return this form to me. My application cannot be processed without this form.
____________________________________________
Applicant’s Signature
________________________
Date
INFORMATION BELOW TO BE COMPLETED BY EXPERIENCE VERIFIER
(not applicant)
Please complete the following information and return this form to the applicant. This form with an original ink signature must be
mailed by the applicant to NBCC. Faxed or photocopied signatures are not acceptable. The applicant and supervisor should retain
copies for their records.
Counseling Supervisor Degree Requirement:
All endorsers must hold a master’s degree or higher in counseling, social work, marriage and family therapy, psychology or
psychiatry. Endorsers are not required to be licensed and cannot be related to the applicant. A counseling supervisor who does
not meet these criteria must return this form to the applicant so another counseling supervisor can be asked for this endorsement.
To the National Board for Certified Counselors:
I have been professionally acquainted with the above-named applicant for ____ years ____ months. I am not related
to this individual either by birth or by marriage. To the best of my knowledge, this applicant is in good standing in the
profession and has demonstrated effective counseling skills with clients while under my supervision. I recommend him/
her for certification through NBCC.
I verify that this applicant for certification has met with me for _________ hours of direct supervision regarding his/her
counseling cases from_____________ (mm/yyyy) to _____________ (mm/yyyy).
Signature of Counseling Supervisor (BLUE ink required)
Counseling Supervisor’s Name, Title (please print)
Date
Degree and Major ( e.g., “M.A.-Counseling”)
Verification of Post-Master’s Experience and Supervision
Professional Certification or License (if credentialed)
Telephone With Area Code
E-mail Address
continued on next page

SECTION 3-Work Experience
Work experience can be verified by work site management/human resources personnel or by a clinical supervisor.
I verify that the applicant named above is/was engaged in counseling work experience for the period from
____________________ (mm/yyyy) to ____________________ (mm/yyyy). I verify that the applicant completed __________
(total number of hours) of counseling work experience. This applicant is/was employed in the position of __________________
____________________________________________________________________________________________ (job title).
This applicant is/was self-employed counselor. I verify that the applicant completed __________ (total number of hours) of
counseling work experience for the period from ________________ (mm/yyyy) to ____________________ (mm/yyyy).
Signature of Experience Verifier (BLUE ink required)
Date
After completing this form, please return it to the applicant.
SECTION 4
Contact Information:
Daytime Telephone: ______________________________________________
Evening Telephone: ____________________________________
Mailing Address: __________________________________________________________________________________________________________
E-mail Address: ___________________________________________________________________________________________________________
Be sure to make copies of all your forms before mailing your application.
NBCC will not return any forms to you or anyone else once your application has been submitted.
This form is to document postgraduate counseling supervision and work experience for counselors who
have already applied for the NCC credential. It is NOT a registration form for a state licensure exam.
If you submit this form for the NCC credential in error or if your documentaion is not approved, the $55
documentation review fee will not be refunded.
Documentation Review Fee: $55
Enclosed is a check or money order—payable to NBCC—in the amount of $55.
My application fee will be covered through the Military Spouse Career
Advancement Account (MyCAA).
Please charge the credit card as listed below in the amount of $55.
Mail packet and payment to
NBCC Certification Department
P.O. Box 77699
Greensboro, NC 27417-7699
Card Type: VISA MasterCard American Express
Name on Card:
Acct. #:
Exp. Date:
Verification Code Numbers (from back of card):
Cardholder Signature: _______________________________________________________
Date: ________________________