Professional Counselor --Transcript/Course 2017

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH
VERIFICATION OF COURSE OF STUDY

Professional Counselor
TO BE COMPLETED BY CANDIDATE

Applicant: Please complete the top portion of this form and forward it to the educational program from which you completed coursework.
Applicant Name*

First NameLast Name
Social Security Number
Social Security Number
Educational Program Location*
Educational Program Location
TO BE COMPLETED BY EDUCATIONAL INSTITUTION ONLY
The applicant named above is applying for Connecticut licensure as a professional counselor. Please provide the following information regarding the course of study that such applicant completed while enrolled in your institution.
Human Growth and DevelopmentCareer CounselingSocial and Cultural FoundationsAppraisals or Tests and Measurements for Individuals and GroupsCounseling Theories and TechniquesResearch and EvaluationGroup CounselingProfessional Orientation to Mental HealthCounselingAddiction and substance abuse counselingTrauma and crisis counselingDiagnosis and Treatment of Mental and Emotional Disorders
YesNo
Date Matriculated

MonthDayYear
YesNo
If no, how many credits were completed.
Credits Completed
YesNo
YesNo
Signature of Authorized Representative
Enter Full Legal Name
I affirm or attest that this is my legal signature.
Date

MonthDayYear
Title
Title
Institution
Institution
Daytime Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please complete and return this form to:

Department of Public Health
Professional Counselor Licensure
410 Capitol Avenue MS# 12APP
P.O. Box 340308
Hartford, CT 06134-0308
Should be Empty:

STATE OF CONNECTICUT

VERIFICATION OF COURSE OF STUDY