According to the Michigan Department of Regulatory Affairs your Professional Disclosure Statement must include the following:

 

YOUR PROFESSIONAL DISCLOSURE STATEMENT MUST INCLUDE ALL OF THE FOLLOWING INFORMATION:

 

1. Your name, business address, and telephone number. (If not currently employed provide your name, address and telephone number as shown on your application for licensure.)

 

2. A description of your practice.

 

3. A description of your education and experience.

 

4. The fee you charge your clients or if you do not charge a fee.

 

5. The following information must be included in your Professional Disclosure Statement in the event your client(s) would like to file a complaint regarding your counseling services. This address and phone number should not be used for any other purpose.

Michigan Department of Licensing and Regulatory Affairs

Enforcement Division Allegations Section

P.O. Box 30670

Lansing, MI 48909

(517) 373-9196 6.

If you are applying for the limited counselor license, you must include the name of the licensed professional counselor who will be supervising your 3000 hours of post-degree experience. In  addition, this document must include the following statement,

“I agree to supervise (insert your name) for the required post-degree counseling experience.”

Supervisors Signature____________________________   Supervisor’s License #____________________________

This statement must be signed by the supervising licensed professional counselor and must include his/her license number. 7. You may either write your own professional disclosure statement using these instructions or the templates that are on the counseling profession webpage located at www.michigan.gov/healthlicense. PLEASE NOTE: There are separate templates for the limited and the full license application.

 

Full Application Packet can be found HERE