OBLPCT - Application for Temporary Reciprocal Licensure (03/20)
State of Oregon
BOARD OF LICENSED PROFESSIONAL COUNSELORS AND THERAPISTS
3218 Pringle Road SE, Suite 120 Salem, OR 97302
503-378-5499 Oregon.gov/OBLPCT
APPLICATION FOR TEMPORARY RECIPROCAL LICENSURE
Application for (check one):
CERTIFIATION
I hereby apply for temporary reciprocal licensure under the standards, qualifications and procedures established under
Oregon Revised Statutes (ORS) and Oregon Administrative Rules (OAR). I have read and understand the laws, rules,
and ethical code provisions that apply to my Oregon practice. I understand that the Board may request further
information or documentation to clarify my application. I authorize the release of any information pertinent to this
application. I am currently licensed in good standing to practice as a professional counselor or as a marriage and family
therapist in another state or the District of Columbia. I have no restrictions or limitations upon or investigation or
disciplinary action pending against my license in any jurisdiction.
I understand that I am not allowed to provide mental health services in Oregon until the Board notifies me that my
temporary license has been issued. The scope of my practice as a temporary licensee is limited to the delivery of mental
health care services through confidential electronic communications to persons located in Oregon in order to meet the
immediate needs of Oregonians in response to the coronavirus emergency. My practice in Oregon is subject to the
Code of Ethics as set forth in OAR Ch. 833, Div. 100 and the compliance procedures in OAR Ch. 833, Div. 110. My
reciprocal licenses can be valid for no longer than 180 days from the effective date of this rule.
I certify that all representations made in this application are true and correct to the best of my knowledge.
Temporary Licensed Marriage and Family Therapist
Temporary Licensed Professional Counselor
Page 1
Zip Code:
State:
Phone:
City:
Street Address:
Office Name:
Middle Name:
First Name:
Last Name:
Email:
Gender:
Female
Male
Date of Birth:
Non-binary
List all professional health care licenses or registrations, whether current or not:
Issue Date
License #
Current Status
Jurisdiction and License Type
Degree Date:
School:
Type:
Signature:
Date:
Submit this signed form to: lpct.board@oregon.gov, or:
Status1
Sign Digitally & Submit by Email
click to sign
signature
click to edit
OBLPCT - Application for Temporary Reciprocal Licensure (03/20)
Required Disclosure: You are required to provide your Social Security Number to the Oregon Board of
Licensed Professional Counselors and Therapists as part of your application for professional license or
temporary authorization. Your Social Security Number will be used for child support enforcement, tax
administration purposes and mandatory reporting to the Federal National Practitioner Data Bank (NPDB)
only, unless you authorize other uses of the number. ORS 25.785; ORS 305.385; 42 USC §666(a)(13); 42
USC §405 (c)(2)(C)(i); and 45 CFR part 61.
NAME:
(Please type or print clearly)
SOCIAL SECURITY NUMBER:
SOCIAL SECURITY NUMBER AUTHORIZATION FORM
STATUTORY REQUIREMENTS REGARDING SOCIAL SECURITY NUMBERS
Oregon Board of
Licensed Professional Counselors and Therapists
Voluntary Disclosure: You may voluntarily provide your Social Security Number to the Oregon Board
of Licensed Professional Counselors and Therapists for the purpose of collecting debts owed to the State
of Oregon. ORS 293.223; OAR 122-085-0200.
I voluntarily provide my Social Security Number to the Oregon Board of Licensed Professional
Counselors and Therapists for the purpose of collecting debts owed to the State of Oregon.
Yes No