Mhc-Form 5 Premasters Internship Form (Page 2 of 2) in pdf

HC - FOR

Definition of an Approved Supervisor:

An approved supervisor is a mental health practitioner who meets the qualifications listed under subcategory (a), (b), (c),

(d), or (e); all of these approved supervisors must have five

years of full time or the equivalent part time postgraduate

(5 )

clinical mental health counseling experience.

(a) L HC; a currently licensed mental health counselor.

(b) A CC HC; a Certified Clinical

ental Health Counselor who holds a currently valid certificate.

1. has a master's degree in social work (LICSW) and is licensed for independent clinical practice;

2. has a master's degree in marriage and family therapy; (L FT)

3. has a doctoral degree in clinical, counseling or developmental psychology or a medical

degree with a sub-specialization in psychiatry (Psychologist or Psychiatrist).

(d) A licensed mental health practitioner who has:

1. a master's or doctoral degree in rehabilitation counseling, pastoral counseling, psychiatric nursing,

developmental or educational psychology, or related fields and;

2. successfuIly completed a Supervised Clinical Experience; and

3. achieved a passing score on the NC HCE licensure examination.

(e) An out of state supervisor who is a licensed mental health practitioner (in states that have licensure in their

discipline) and who meets the qualifications for licensure for independent clinical practice in

assachusetts in his/her

respective discipline.

(f) For the specific purpose of the college supervision (e.g. support seminars) of students in a practicum or

internship, an approved supervisor may be a mental health practitioner who:

1. holds a teaching or supervisory position in an educational institution which trains mental health

counselors; and

2. holds a graduate degree in mental health counseling or a related field.

Site supervisors for practica and internships must meet the qualifications for Approved Supervisor (a), (b), (c),

(d), or (e).

Please list which of the above describes your license:

ASSACHUSETTS SUPERVISOR:

______________________________________

# ________________________________

LICENSE/CERTIFICATE

OUT OF STATE SU ERVISOR:

Please attest that you meet the qualifications for individual clinical

practice in

assachusetts by your signature below.

License # _____________ State __________ Licensure type __________________________

_________________________________________________________

APPLICANT’S NA E:

Massachusetts LMHC application

Updated 9/2012

Mhc-Form 5 Premasters Internship Form Page 2