Erik Schoen, PresidentNEVADA STATE BOARD OF EXAMINERS FOR9436 W. Lake Mead Blvd Suite 11-J
Richard Harrison, M.A., Vice PresidentMARRIAGE & FAMILY THERAPISTS ANDLas Vegas, Nevada 89134-8342
Jake Wiskerchen, Secretary/TreasurerCLINICAL PROFESSIONAL COUNSELORSOffice: (702) 486-7388
Hal Taylor, J.D., MemberFax: (702) 486-7258
Jean E. Griffin, Ed.D., Membermarriage.nv.gov
John Nixon, Ed.D., Member
Wendy Nason, M.A., Member
Roberta Vande Voort, Member
2017 RENEWAL FOR CLINICAL PROFESSIONAL COUNSELORS (CPC) LICENSURE
Renewal Fee: $150.00.
Late Fee after December 31: $100.00.
To apply and pay online, please use the form below. To apply and pay by check or mail, please click here
License NumberFirst NameMidLast NamePhone
Address CityStateZipEmail
As a Licensed Clinical Professional Counselor in the State of Nevada, it is required that you register and submit an
annual fee to the Board of Examiners for Marriage & Family Therapy and Clinical Professional Counselors.

Please keep the Board apprised of any change of address you may have during the year.
ETHICAL CONSIDERATIONS FOR LICENSE RENEWAL/REGISTRATION: (Please check one)
1. Have you been indicted or convicted of a misdemeanor (other than a traffic vilation), gross misdemanor,
or felony within the past 5 years? Yes No
2. Have you ever had a complaint with a clinical professional counselor certifying, licensing, or registering body or any professional
association against you for alleged unethical behavior or unprofessional conduct within the past 5 years? Yes No
3. Have you ever been censured or had any disciplinary action taken against you for unethical behavior, unprofessional conduct or any other grounds
by a professional organization within the last 5 years?
Yes No
4. Have you ever been investigated, charged with, or convicted of unprofessional conduct, negligence, or professional incompetence by any
certification or licensing board or other agency, institution, or professional organization within the last 5 years?
Yes No
5. Have you used any alcohol, narcotic, barbiturate other drug affecting the central nervous system, or other drug which may cause physical
or psychological dependence, either to which you were addicted or upon which you were dependent within the last 5 years?
Yes No
6. Have you been diagnosed or treated for any physical, emotional or mental illness or disease, including drug addiction or alcohol
dependency, which limited your ability to practice behavioral sciences with reasonable skill and safety within the past 5 years? Yes No
7. Have you used controlled substances which were obtained illegally or which were not obtained pursuant to a valid prescription order or
which were not taken following the direction of a licensed health care provider within the past 5 years?
Yes No
8. Has any state, jurisdiction, province, or professional organization denied your application for credentials or professional membership
within the past 5 years? Yes No
9. Have you ever been sued for malpractice, or agreed to pay a settlement in a malpractice suit?
Yes No
IF ANY OF THE ABOVE QUESTIONS HAVE BEEN ANSWERED "Yes," please explain circumstances and outcome
to the board via e-mail or comment box below.

Active Renewal $150 Inactive Renewal $150 2nd Yr Inactive: No Charge 3rd Yr Inactive: No Charge
If on "Inactive Status" I understand that I will not practice Clinical Professional Counseling.

I have completed 20 CEU's for 2017 I am inactive I was NEWLY licensed in 2016, I will complete 20 CEU's in 2017

I wish to: RENEW REACTIVATE RETIRE RESIGN my license.
Attention: This license renewal/registration form and subsequent information supplied may be subject to disclosure under Nevada law.

CHILD SUPPORT STATEMENT
Nevada state law requires that all applicants for issuance of a license be required to provide the following information concerning
the support of a child. As part of this application, your responses to these questions are given under oath and any response given
hereto which is false, fraudulent, misleading, inaccurate or incomplete, will result in your application being denied. You must mark
one of the following responses. Failure to indicate which provision applies will result in your application being denied.
I am not subject to a court order for the support of a child.
I am subject to a court order for the support of one or more children and am in compliance with an order or am in compliance
with a plan approved by the district attorney or other public agency enforcing an order for the repayment of the amount owed
pursuant to the order.
I am subject to a court order for the support of one or more children and am NOT in compliance with an order or a plan approved
by the district attorney or other public agency enforcing the order for the repayment of the amount owed pursuant to the order.
CEU REPORTING FORM:
To maintain licensure in the State of Nevada, a Marriage & Family Therapist and Clinical Professional
Counselor is required to acquire at least 20 hrs of Continuing Education Units per year immediately preceding
the date of renewal. At least 3 hrs must be in Ethics. At least 2 hrs must be in Suicide Prevention. Not more than
10 hours can be distance education. At least 1 hr must be in Supervision for Supervisors. (IAW NRS 641A160, NAC
641A.131 and NAC 641A.133.)
Ethics Course:
Course TitleOrganization Sponsor TypeDateCEU
Approval
Number:
CEU
Hrs:
Online
In Person
Suicide Prevention Course:
Course TitleOrganization Sponsor TypeDateCEU
Approval
Number:
CEU
Hrs:
Online
In Person
Supervision Course:
Course TitleOrganization Sponsor TypeDateCEU
Approval
Number:
CEU
Hrs:
Online
In Person
Other:
Course TitleOrganization Sponsor TypeDateCEU
Approval
Number:
CEU
Hrs:
Online
In Person
Online
In Person
Online
In Person
Online
In Person
Online
In Person
Online
In Person
Online
In Person
Online
In Person
ADDITIONAL COMMENTS
Please include any comments, questions or additional information below:

PAYMENT INFORMATION
First NameLast NameExpiration Date MM/YYYY
/
Billing AddressCityState (XX)Zip (XXXXX-XXXX)
Account Number (no dashes)e-mail Address for receipt.
By entering my credit card and clicking "Submit" I authorize the charge to my card of the amount due for my license application.