Mental Health Counselor Form 4f - Certification Of Licensed Experience - 2015 Page 2
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2Section II: Certification of Licensed Experience
Instructions to Licensed Colleague: Complete Section II, Items A and B, sign and date the affidavit and send both pages of this form
directly to the address at the end of this form. Your signature on this form must be notarized by a Notary Public. This form will not be
accepted if returned by the applicant. You must include a copy of your license.
A. Licensed Colleague’s Qualifications:
I am a licensed _______________________________________________________________ in ______________________________
Professional Title
State
____________________________________________________________________________
_____________________________________________________________
License number (Attach a copy of your license if other than New York)
Date licensed
B. Experience Information: I am attesting that ________________________________________________________________________
Applicant Name
practiced Mental Health Counseling (defined below) as follows.
_____________________________________________________________________________________________________________
Address of setting where experience took place
City
State
Zip Code
Dates of Experience:
From _______ / _______ / _______ To _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
The practice of Mental Health Counseling is defined as 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 is 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.
Affidavit with Acknowledgement (Notarization required.)
Licensed Colleague
I declare and affirm that the statements made in the foregoing application, including any attached statements, are true, complete and
correct and that the experience I am attesting to meets the definition of Mental Health Counseling. This form must be signed and
dated in the presence of a Notary Public.
Check here if you are attaching additional information.
Signature: ______________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Print Name: _____________________________________________________________________
Address:________________________________________________________________________
________________________________________________________________________
Phone: _________________________________ Fax: ___________________________________
E-mail: _________________________________________________________________________
Notary
State of __________________________________________________ County of __________________________________________
On the ____________ day of ______________________ in the year __________ before me, the above signed, personally appeared
__________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual
whose name is subscribed to this application and acknowledged to me that he/she executed the application and swore that the
statements made by him/her in the application and all supporting materials are true, complete, and correct.
Notary Public signature _________________________________________________________________________________________
Notary ID number _______________________________
Notary Stamp
Expiration date __________ / __________ / __________
Month
Day
Year
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
Mental Health Counseling Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Mental Health Counselor Form 4F, Page 2 of 2, Rev. 11/15
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