Apply for a provisional genetic counselor license

• Social Security Number SSN
• Date and place of birth
• Mother's maiden name
• 2x2 passport style color photo with a white or off-white background. Copies and printer generated photos are not acceptable.
• A notary signature
• Official transcripts in a signed and sealed envelopes for all undergraduate programs/degrees, accredited (per ABGC or ABMMG) master’s or PhD genetic counselor programs/degrees, and any other post-secondary programs/degrees.
  • Transcripts must be complete and state the degree and date conferred in mm/dd/yyyy format.
• Verification of licensure status, in signed, sealed envelopes, from any state or jurisdiction in which you now or have previously held any professional license. The state or other jurisdictions must send verifications directly to the Board.
• Submission of the Criminal Offender Record Information Request Form (CORI), found below

If applicable

• If you hold, or have ever held, any professional license, you must request and submit a National Practitioner Data Bank-Healthcare Integrity and Protection Data Bank Self-Query. To request a Self-Query, please contact the National Practitioner Data Bank. Include the original report with this application. Make a copy for your records.
  • Note: If you don't hold and have never held any professional licenses in any other state or jurisdiction, you don't need to submit a National Practitioner Data Bank self-query
• If you answer "yes" to any of the questions 14-19:
  • Attach a separate sheet explaining the circumstances

The address printed on your license is a public record that is available to anyone who requests it. If you are using your home address, you may wish to consider changing this to an office address. You may request address changes online at the board’s website, or you may get a form online to submit to the Board’s office.