Professional Reviewer Interest Form Volunteer to be a Professional Reviewer Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone Number *Email *EmailConfirm EmailLicense Type *Please select your license type from the drop down menu.Licensed Professional Counselor (LPC)Licensed Marriage and Family Therapist (LMFT)Licensed Baccalaureate Social Worker (LBSW)Licensed Master’s Social Worker (LMSW)LMSW advanced practitioner recognition (LMSW-AP)Licensed Clinical Social Worker (LCSW)Licensed PsychologistLicensed Psychological AssociateLicensed Spec in School PsychologistAre you a supervisor? *YesNoDo you hold Social Work Independent Practice Recognition?YesNoLicense Number *Degree(s) HeldYears of Licensed Practice *Areas of Particularized Expertise (select all that apply) *General ethical practice standardsTreatment methodsFamily related issuesChild custody evaluationsPsychopathologyAdministrative / Record keepingSupervisor / Supervisee relationshipIn what setting has your professional experience been? (select all that apply) *Private practice,Solo practice,Hospitals,Government agencies,VirtualOtherIf other, please explain below.Have you ever acted as a professional reviewer for the Council? *YesNoHave you ever testified at a hearing before the State Office of Administrative Hearings (SOAH)? *YesNoHave you ever had a criminal conviction or a disciplinary action taken against a professional license? *YesNoPlease attach your resume/CV. Drag & Drop Files, Choose Files to Upload Submit
