Professional Counselor -- CE Waiver
  • Public Health: Office of practitioner licensing and certification - Professional Counselor

    Public Health: Office of practitioner licensing and certification - Professional Counselor

    DPH Data Management and Governance (PLIS)

  • AFFIDAVIT

  • Application for (Please check one) :*

  • I,   *   *      being duly sworn, attest that:

  • 1. I am a professional counselor licensed in the State of Connecticut. 

    2. During the exemption period from   Pick a Date*   to   Pick a Date*   I did not/will not actively engage in the practice of professional counseling in the State of Connecticut; 

  • OR,


    I hereby declare my eligibility for a waiver/extension of the continuing education requirements based on a medical disability/illness pursuant to Regulations of Connecticut State Agencies Section 20-195cc-6. I certify that due to a medical disability/illness, I am unable to complete the continuing education requirements from   Pick a Date* to   Pick a Date*   

  • 3. I, therefore, claim an exemption for the above-specified period from the Regulations of Connecticut State Agencies Section 20-195cc-1 through 20-195cc-5 which specifies that each licensee actively engaged in the practice of professional counseling must complete a minimum of 15 contact hours during the preceding registration period.


    4. I understand that, should I resume the practice of professional counseling in the State of Connecticut, I would be required to complete the requirements listed in Section 20-195cc-7 of the Regulations of Connecticut State Agencies.


    5. The above statements are true to the best of my knowledge and belief.

  • Date:*
     - -

  • Subscribed and Sworn before me this day of *,   
    20 

  •  

  • Phone: (860) 509-7603
    Telephone Device for the Deaf (860) 509-7191
    410 Capitol Avenue – MS # 12MQA
    P.O. Box 340308 Hartford, CT 06134
    An Equal Opportunity Employer

  • Should be Empty: