Mental Health Counselor Form 4b - Certification Of Supervised Experience - 2015
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1
2The University of the State of New York
Mental Health Counseling Form 4B
The State Education Department
Office of the Professions
Certification of Supervised Experience
Division of Professional Licensing Services
Assigned Number (from Form 4):
Applicant Instructions
1. Complete Section I. In item 3, enter your name exactly as it appears on your Application for Licensure (Form 1). Be sure to sign and
date item 7.
2. Send this entire form and a copy of Appendix A to your supervisor(s) to complete Section II. The supervisor(s) must return both pages
of the form directly to the Office of the Professions at the address at the end of the form. This form will not be accepted if returned
by the applicant.
Section I - Applicant Information
1.
Social Security Number
2.
Birth Date
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3.
Print Your Name Exactly As It Appears On Your Application for Licensure (Form 1)
Last
First
Middle
4.
Mailing Address (You must notify the Department promptly of any address or name changes)
Line 1
Line 2
Line 3
City
State
ZIP Code
Country/
Province
5.
Name at time of employment (if different than above)
6.
Name of supervisor
Assigned number from Form 4
I practiced Mental Health Counseling as defined below:
“Mental Health Counseling is the evaluation, assessment, amelioration, treatment, modification, or adjustment to a disability, problem, or
disorder of behavior, character, development, emotion, personality or relationships by the use of verbal or behavioral methods with
individuals, couples, families or groups in private practice, group, or organized settings; and the use of assessment instruments and
mental health counseling and psychotherapy to identify, evaluate and treat dysfunctions and disorders for purposes of providing
appropriate mental health counseling services.”
Duration of supervised experience
Date beginning
Date ending
mo.
day
yr.
mo.
day
yr.
Total hours practicing Mental Health Counseling
(no more than 50% of the total hours may consist of indirect hours)
7.
I request and give my permission to the individual listed in item 5 above to complete Section II of this form and mail it to the New York
State Education Department at the address at the end of this form, and to release any other information requested by the State Education
Department in connection with my application for licensure. I also declare and affirm that the statements made in this application,
including accompanying documents, are true, complete and correct. I understand that any false or misleading information in, or in
connection with, my application may be cause for denial or loss of licensure and may result in criminal prosecution.
Applicant's Signature
Date
Mental Health Counseling Form 4B, Page 1 of 2, Revised 10/17
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