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Mental Health Counselor Form 1

Application for Licensure

The University of the State of New York

The State Education Department

Office of the Professions

Applicants Must Complete All Pages Of This Application In Ink

Division of Professional Licensing Services

All applicants for licensure must complete this form and submit it with the $371 licensure and first registration

fee directly to the Office of the Professions at the address at the end of this form. You must answer all questions

and provide all information requested unless otherwise indicated. Failure to complete all required parts of the

application will delay its review. You must sign and date the Affidavit on this form in the presence of a

18 $371 ER

Notary Public.

Check what you are applying for

Initial Licensure

Licensure by Endorsement

Social Security Number

Birth Date

Month

Day

Year

(Leave this blank if you do not have a U.S. Social Security Number)

Telephone/Email Address

Print Name

Daytime Phone

Last

Home or

Business

First

Area Code

Phone

Middle

Email Address (please print clearly)

Licensee business address, phone and email address are public information. Failure to

Home or

Business

indicate business or home on this form for each item will deem it public information.

Mailing Address

Home or

Business

(You must notify the Department promptly of any address or name changes)

Line 1

Line 2

New York State DMV ID Number

(Driver or Non-Driver ID)

Line 3

City

(Leave this blank if you do not have a

New York State DMV ID Number)

State

ZIP Code

Country/

Province

Reasonable Testing Accommodations for Individuals with Disabilities. (check if applicable)

I have been diagnosed as having a disability and require special testing accommodations and am submitting the Request for Reasonable Testing

Accommodations form to the address at the end of the form. I understand that I will not be able to test until I submit the appropriate documentation and

am approved to test with accommodations. (Visit the Office of the Professions' Web site at for information on obtaining the form.)

10. Name as it appears on degree or other credentials (if different from above)

Yes

11. Have you previously applied for New York State licensure in any profession licensed under New York State

Education Law?

If "yes", in what profession(s)?

12. Have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime

Yes

(felony or misdemeanor) in any court?

13. Are criminal charges pending against you in any court?

Yes

14. Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled,

Yes

accepted surrender of, suspended, placed on probation, refused to renew a professional license or certificate held

by you now or previously, or ever fined, censured, reprimanded or otherwise disciplined you?

15. Are charges pending against you in any jurisdiction for any sort of professional misconduct?

Yes

16. Has any hospital or licensed facility restricted or terminated your professional training, employment, or

Yes

privileges or have you ever voluntarily or involuntarily resigned or withdrawn from such association to avoid

imposition of such measures?

NOTE: If you answer "Yes" to any questions numbered 12-16, submit a letter giving a complete detailed explanation. Include copies of any court records

including a Certificate of Disposition. If there are offenses in multiple courts, please provide the same for each action. If the court can no longer provide

documentation, you must request, from the court, a letter stating why they cannot provide the documents. While your application is pending, you must notify

the Division of Professional Licensing Services if the answers to any of these questions have changed.

Mental Health Counselor Form 1, Page 1 of 4, Revised 10/17