Mhc-Form 5 Premasters Internship Form

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HC - FOR
5
PRE- ASTERS INTERNSHIP FOR
Name of Applicant: _____________________________________________________________
INSTRUCTIONS: lease duplicate this form as necessary. See following page for the definition
of Approved Supervisor. LEASE RINT CLEARLY OR TY E.
INI U
REQUIRE ENTS: 600 hours which includes: 240 hours of direct client contact and 45 hours
of supervision with a minimum of 15 hours of individual supervision and 15 hours of group supervision.
(50 hours of supervision by a LMHC must be documented during either pre-masters or post-masters
experience.)
Remainder of Form to be completed by Approved Supervisor
Name of Supervisor: ______________________________________________________
Supervisor's Title: ________________________________________________________
Supervisor's License Type and Number: __________________________________________
Supervisor's phone number: _________________
Name/Address of Clinical Facility: ______________________________________________________
____________________________________________________________________________________
Dates of Supervision of the Applicant: From: ___ / ___ / _____To: ___/__ _/_____(month/date/year)
The applicant worked ____ hours per week for ____ weeks for a total of ___________ MH experience
hours
Number of direct, face-to-face, clinical hours completed during this period:______________________
Number of Supervision Hours provided during this period by this supervisor:
Individual: __________ Group: __________
Has any disciplinary action been taken against you by any of the following: (if yes, please submit
detailed explanation)
rofessional Association or Organization:
Yes: _____
No: _____
Governmental Authority (e.g. rofessional Licensing: Board): Yes: _____
No: _____
Third arty Insurance Carrier:
Yes: _____ No: _____
Credentialing Board:
Yes: _____
No: _____
I have read the definitions of Approved Supervisor listed in 262 CMR and/or provided on the following
page and believe that I qualify as an approved supervisor, including having at least 5 years of post-
graduate clinical mental health counseling experience at the time that supervision was provided and/or
qualifying under category f).
The undersigned states that under the pains and penalties of perjury, the above statements
are true and correct.
____________________________________________________________ ______________________
Signature of Approved Supervisor
Date
Massachusetts LMHC application
Updated 9/2012

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