Mental Health Counseling Form 5 - Application For Limited Permit

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Department Use Only
The University of the State of New York
Mental Health Counselor
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Form 5
Division of Professional Licensing Services
Application for Limited Permit
Applicant Instructions
1. A limited permit authorizes practice as a Mental Health Counselor under the general supervision of an
appropriately licensed professional. Complete Section I. Be sure to sign and date item 9. Give your
prospective supervisor a copy of Appendix A along with both pages of this application. It is your
responsibility to ensure that the supervisor fully completes Section II.
2. You may apply for a limited permit either at the same time as or after submitting an application for a license
18
$70
PR
1
as a Mental Health Counselor in New York State. If you have not yet filed an Application for Licensure
(Form 1) and the licensure fee ($371), you must submit them with this form and the limited permit fee.
Permit Number
Permits cannot be issued until all required documentation has been received and approved.
3. Submit this application and the $70 fee to the Office of the Professions at the address at the end of this
form.
Date Issued
4. If you change or have additional settings or supervisors after a permit is issued, you must obtain a re-
issued permit. Complete a new Form 5 with each prospective supervisor, and return it to the Office of the
Professions. A new fee is not required for a permit issued as a result of a change in supervisor or setting.
Date Expires
5. The limited permit is valid for a period of two years. The permit may be extended for up to two additional
one-year periods at the discretion of the Department if the Department determines that you have made
good faith efforts to successfully complete the examination and/or experience requirements but have not
passed the licensing examination or completed the experience requirement, or have other good cause as
Initials
determined by the Department for not completing the examination and/or experience requirement. To apply
for an extension you must submit a new application for a limited permit and a fee of $70 along with a
justification for the extension.
6
Section I: Applicant Information
6.
Telephone/E-Mail Address
Daytime phone
2
2.
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Area Code
Phone
3
3.
Birth Date
Month
Day
Year
E-mail Address
(please print clearly)
4
4.
Print Name
Last
First
7
7.
I am applying for:
Middle
 Original Permit
 Additional setting
5
5.
Mailing Address
(You must notify the Department promptly of any address or name changes.)
 Additional supervisor
Line 1
 Change of setting
 Change of supervisor
Line 2
 Extension (attach justification)
Line 3
City
State
Zip Code
Country/
Province
8
7.
Name of prospective supervisor: _______________________________________________________________________________
9
8.
Attestation
I declare and affirm that the statements made in the foregoing application are true, complete and correct. Any false or misleading
information in, or in connection with, my application may be cause for denial of permit and licensure and may result in criminal
prosecution.
_________________________________________________________________________
_________________________________
Applicant's signature
Date
Mental Health Counselor Form 5, Page 1 of 2, Rev. 8/15

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