Post-Graduate Verification - Mental Health Counselor

Download a blank fillable Post-Graduate Verification - Mental Health Counselor in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Post-Graduate Verification - Mental Health Counselor with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.


Post-graduate Verification -
Access this form via website at:
Instructions to the Applicant: Complete Section 1, have your supervisor complete Section 2 to verify your post-graduate experience, then
attach the completed form to your application before submitting it to the department. Please note that your supervisor must sign the form
before a notary public. You must complete at least 3000 hours of post-graduate experience in the practice of mental health counseling
with 100 hours of face-to-face clinical supervision in no less than two years and in no more than four years.
Name (First, Middle)
Date of Birth
Address (Include Apt. No., City, State and Zip Code)
Social Security No.
Phone No.
Date of Graduation
The person named above is applying for a mental health counselor license in Hawaii. Please complete Section 2 to verify the applicant
completed the post-graduate experience under your supervision, sign the form before a notary public, then return the completed form to the
applicant. To correct an error in Section 2, please draw a single line through the incorrect information and initial. DO NOT use correction fluid
or write over incorrect information.
Total Hours
Total hours of
Name of Post-graduate Firm
Description of Counseling
Setting and Mental
Dates (mo/day/yr)
Experience in Mental
Address, City, State
Health Services Provided
Health Counseling
Please attach a brief summary of the duties that the applicant performed during the post-graduate period listed.
Affidavit of Supervisor:
I hereby attest that I supervised the post-graduate experience of the individual listed above and that the information in
Section 2 is accurate. I further certify that during the post-graduate dates above, I was: (check one)
A licensed mental health counselor.
A licensed psychologist, licensed clinical social worker, advanced practice registered nurse with a specialty in mental
health, a physician with a specialty in psychiatry, or a licensed marriage and family therapist.
Subscribed and sworn to before me this
day of
A.D. 20
Notary Signature:
Notary Public, State of:
My commission expires:
Signature of Supervisor
Print name of Supervisor:
Print Name:
Doc. Date:
No. of Pages:
Notary Name:
Circuit Court:
Phone No.: (
Doc. Description
State of Licensure:
Type of Lic.:
License No.:
Notary Signature:
Initial date of License:
Expiration date:
This material can be made available for individuals with special needs. Please call the
Print Form
MHC-04 0813R
Licensing Branch Manager at (808) 586-3000 to submit your request.


00 votes

Related Articles

Related forms

Related Categories

Parent category: Education