• Licensure Education Assistance Program

    APPLICATION
  •  -  -
    Pick a Date
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  •  -  -
    Pick a Date
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Clinical Information

  • Supervisor Information

    Name of your Supervisor, dates, and hours of supervision hours they provided for you:
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  • Availability

    BBC LEAP© is an intensive program to prepare you for licensure. Complete the following chart with your availability. These times will include a minimum of ten (10) community service hours per week (counseling, trainings, workshops, community outreach. Etc.), study group is a minimum of 3 hours per week, individual/group supervision is a minimum of 1 hour per week.
  • Study Group: Total of 3 hours per week

  • Documentation

    The following information must be submitted along with your completed application for review:
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • VERIFICATION

    I verify that that this application is in the original format as supplied by the Black Brain Campaign Licensure Education Assistance Program© and has not been altered or otherwise modified in any way. I verify that the statements in this application are true and correct to the best of my knowledge, information and belief. I understand that false statements that are made may result in suspension, revocation or denial of this licensure program.
  • Clear
  • Should be Empty: