Affidavit and Release of Information (Professional Counselors)

Owner: State, Professional Regulations - Board of Professional Counselors of Mental Health

Link: http://dpr.delaware.gov/boards/profcounselors/documents/relofinfo_form.pdf

Referring Page - Forms

Description: The undersigned applicant for Professional Counselor of Mental Health licensure, being sworn, deposes and affirms that the following is a complete list of any and all licensing jurisdictions in which s/he has formerly and currently practiced as a licensed mental-health professional. The applicant hereby authorizes all such jurisdictions to release any and all information regarding his/her disciplinary history and current status to the Delaware Board of Mental Health and Chemical Dependency Professionals.

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