TX HHS Form 3262. Licensed Chemical Dependency Counselor Intern Supervised Work Experience Documentation

Form 3262 is the official document used in Texas to verify and report the supervised work experience hours completed by a Licensed Chemical Dependency Counselor (LCDC) Intern. It is submitted directly to the Texas Health and Human Services Commission (HHSC) by a Clinical Training Institution (CTI) coordinator or a Certified Clinical Supervisor (CCS). This form plays a crucial role in transitioning an intern toward full LCDC licensure, making accuracy and regulatory compliance essential.

Purpose of Form 3262

This form exists to document the completion—or partial completion—of a counselor intern’s required 4,000 hours of supervised work experience. Texas law requires that these hours be formally tracked and submitted under strict administrative rules (26 TAC §562.21). HHSC will only accept hours submitted through this official process, which ensures accountability and protects the integrity of the LCDC credentialing system.

Form 3262 is required in three main situations:

• When the intern completes all 4,000 required supervised hours.
• When the intern leaves a CTI site before completing all hours.
• When the intern changes their Certified Clinical Supervisor.

Explanation of Each Section

Section 1 – Purpose of Submission

This section clarifies why the form is being submitted. The CTI coordinator or CCS must select the appropriate reason. Misselecting the purpose is one of the most common errors and can lead to processing delays.

Section 2 – Counselor Intern Information

This collects core identifying details, including the intern’s name, Social Security number, contact information, and active registration dates. HHSC uses it to match the hours to the correct intern profile. Ensure dates match the intern’s active registration period—hours earned outside that range will not count.

Section 3 – CTI Site Information

This section is required only if the supervised hours were completed at a licensed CTI. It includes the facility name, license number, contact details, and address. A missing or incorrect site license number is a frequent reason forms are rejected.

Section 4 – CCS Information

If a CCS—not a CTI—supervised the work, this section documents the supervisor’s identity and license. HHSC must be able to verify the supervisor’s credential type and validity during the service dates.

Section 5 – Training Information

This is where the actual work experience hours are detailed. It includes:

• Start and end dates.
• Job title during those dates.
• Weekly hours worked (cannot exceed 40 hours per TAC rules).
• Total hours in the KSA (Knowledge, Skills, and Attitudes) dimensions.

The Texas Administrative Code strictly limits accruable hours, and any week showing more than 40 hours will be rejected.

Section 6 – CCS Signature and Attestation

If a CCS supervised the hours, they must affirm the accuracy of the documented training. The attestation carries legal responsibility, and providing false information can lead to disciplinary action.

Section 7 – CTI Coordinator Signature and Attestation

This section verifies whether the CTI coordinator provided direct supervision or whether a Qualified Credentialed Counselor (QCC) was involved. Each supervisor is accountable for overseeing only job duties relevant to the KSAs defined by 26 TAC §562.1(28).

Section 8 – GovDelivery Updates

Interns and coordinators can indicate participation in GovDelivery updates, a notification system for important changes in licensure requirements.

Practical Recommendations for Completing the Form

• Double-check all dates against the intern’s active registration period.
• Ensure job duties clearly match KSA dimensions—HHSC may request clarification.
• Attach the correct job description; a missing attachment is one of the top causes of rejection.
• Use typed entries whenever possible to avoid misread handwriting.
• Submit the form within 10 working days of hour completion or supervision change.

Real-Life Examples

• Example 1: An intern completes all 4,000 hours at a licensed CTI. The CTI coordinator submits Form 3262 and the job description directly to HHSC within 10 working days.
• Example 2: A CCS supervising an intern at a private practice relocates out of state. Before leaving, the CCS submits the partial hours accumulated so far.
• Example 3: An intern holds two different job titles during the training period. The CTI completes two separate Form 3262 submissions, one for each position.
• Example 4: An intern switches CTIs. The former CTI submits documented hours up to the date of transition.

Required Supporting Documents

• A copy of the intern’s job description (must align with KSAs).
• Separate job descriptions if multiple job titles were held.
• The completed and signed Form 3262.

FAQ

• Who is allowed to submit Form 3262? Only a CTI coordinator or a Certified Clinical Supervisor may submit verified hours.
• Can interns submit their own hours? No. Intern-submitted forms are not accepted.
• What happens if the weekly hours exceed 40? HHSC will reject or adjust the hours, as this violates 26 TAC rules.
• Do job descriptions really matter? Yes. They must show tasks linked to KSAs; otherwise, hours may be disqualified.
• How quickly must the form be submitted? Within 10 working days after completion of the 4,000 hours or a change in supervision.
• Does HHSC track hours internally? No. Only CTIs and CCS supervisors track and verify hours.

Micro-FAQ

• Purpose? To verify supervised work hours for LCDC intern training.
• Who files? CTI coordinators or CCS supervisors.
• Deadline? Within 10 working days of hour completion or supervision changes.
• Attachments? Intern job description(s).
• Where submitted? Email, fax, or mail to HHSC Licensing Unit.
• Hours required? 4,000 supervised work hours.
• Max weekly hours? 40 hours per TAC rules.
• Accepted format? Typed entries preferred; signatures required.
• Can interns submit? No.

Related Forms

• Texas LCDC Application for Initial Licensure
• Form 3248 – Supervisor Verification
• Form 3253 – Clinical Training Institution Site Application

Form Details

• Form Name: Licensed Chemical Dependency Counselor (LCDC) Intern Supervised Work Experience Documentation
• Form Number: Form 3262
• Region: Texas
• Latest Revision: May 2025