Mental Health Counseling Application Forms

Important Notice: If you were ever licensed in this profession in New York State STOP. A New York State professional license is valid for life unless it is revoked, annulled, or suspended by the Board of Regents. To practice in New York State your professional license must be registered. If your registration has lapsed and you need to reregister, do not submit a Form 1. Instead, contact us to request a Delayed Registration Application, or call 518-474-3817 Ext. 570.

Note: For fillable PDF forms, Internet Explorer is the recommended browser.

Applicant Checklist ( PDF 81 KB)
You may print and keep this checklist as a reminder of what forms you need to file. This is for your reference and should not be submitted with your application forms. You should also keep a copy of all application forms submitted.

Online Form 1 - Application for Licensure
All applicants for licensure must initially submit Form 1 along with the $371 licensure and first registration fee. You must answer all questions and provide all information requested unless otherwise indicated. Failure to accurately complete all required parts of the application will delay its review. Additional forms below are required based on the licensure requirements of the profession.

Address/Name Change Form - Optional ( PDF 20 KB)
You are required to notify us within 30 days of any name or address changes. Please read the instructions and complete the appropriate sections of this form.
 
Form 2 - Certification of Professional Education - ( PDF 18 KB)
This form must be submitted directly by the educational institution(s) where you completed your counseling studies. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section before sending the entire form to your educational institution. Be sure to sign and date item 9 and include any fee required by the institution.
  • Section II: The Registrar must complete this section and return both pages of the form in an official school envelope directly to the Office of the Professions at the address at the end of the form. An official transcript is also required if the degree program was not registered by New York State as licensure qualifying at the time you completed the program.

Form 2INT - Certification of Supervised Internship and Practicum - ( PDF 19 KB)
This form must be submitted directly by the educational institution where your supervised internship and practicum in Mental Health Counseling was part of your graduate program. Please note that this form is NOT REQUIRED for graduates of 60 credit hour CACREP accredited or NYS registered licensure qualifying MHC programs. The Office of the Professions will not accept this form if submitted by the applicant. Note: Syllabi cannot be accepted in lieu of completion of this form.

  • Section I: Complete this section before sending the entire form to where your supervised internship and practicum in Mental Health Counseling was part of your graduate program. Be sure to sign and date item 8 and include any fee required by the institution.
  • Section II: The Director must complete this section and return all pages of the form along with any other required documentation in an official envelope directly to the Office of the Professions at the address at the end of the form.

Form 3 - Verification of Other Professional Licensure/Certification - ( PDF 18 KB)
Complete this form if you hold, or have ever held, a license or certificate to practice any profession* in any jurisdiction.

This form must be submitted directly by the licensing/certifying authority. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section before sending the entire form to the licensing/certifying authority of each jurisdiction in which you are or have been licensed/certified. Be sure to sign and date item 8.
  • Section II: The licensing/certifying authority must complete this section, sign, date and return both pages of the form directly to the Office of the Professions at the address at the end of the form.

NOTE: A Form 3 is not required for licenses/certificates issued by the New York State Education Department.

*Profession is defined as professional titles licensed under New York State Education Law. (See page 2 of the Address/Name Change Form for a list of those titles.)

Appendix A - Requirements for Supervised Experience - (PDF PDF 10 KB)
Send this document to the licensed professional(s) who supervised your experience or will supervise your practice under a limited permit and/or the individuals endorsing your application for licensure along with the form you are asking them to complete.
 
Form 4 - Applicant Experience and Endorsement Record - ( PDF 17 KB)
Complete this form and send it to the Office of the Professions at the address at the end of the form. Be sure to sign and date item 8.
 
Form 4B - Certification of Supervised Experience - ( PDF 19 KB)
This form must be submitted directly by the licensed professional(s) who supervised your experience. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section before giving the entire form and a copy of Appendix A (PDFPDF 21 KB) to the licensed professional(s) who supervised your experience. Be sure to sign and date item 6.
  • Section II: The licensed professional(s) who supervised your experience must complete this section and return both pages of the form directly to the Office of the Professions at the address at the end of the form. The supervisor must be the supervisor named on your limited permit, for experience in New York.

A separate Form 4B must be submitted for each supervised experience you list on the Applicant Experience Record (Form 4).

Form 4E - Endorsement Applicant Experience Record - ( PDF 17 KB)
This form is for applicants seeking licensure in New York State by endorsement of a license to practice Mental Health Counseling issued by another jurisdiction. You must have at least 5 years of licensed experience in Mental Health Counseling, in the 10 year period prior to applying for licensure in New York State.

Complete and send both pages of this form directly to the Office of the Professions at the address at the end of the form. Be sure to sign and date item 8.

You must also complete a separate Form 4F for each licensed colleague you list on the Endorsement Applicant Experience Record (Form 4E).

Form 4F - Certification of Licensed Experience - ( PDF 19 KB)
This form is for applicants seeking licensure in New York State by endorsement of a license to practice Mental Health Counseling issued by another jurisdiction. You must have at least 5 years of licensed experience in Mental Health Counseling in the 10 year period prior to applying for licensure in New York State.

This form must be submitted by the licensed colleague(s) who is attesting to your licensed practice as a Mental Health Counselor in another jurisdiction. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section and send the entire form to the licensed colleague who will attest to your experience as a Mental Health Counselor in another jurisdiction. Be sure to sign and date item 6.
  • Section II: The licensed colleague who will attest to your licensed experience must complete this section and return both pages of the form directly to the Office of the Professions at the address at the end of the form.

A separate Form 4F must be submitted for each licensed colleague listed on the Endorsement Applicant Experience Record (Form 4E).

Form 5 - Application for Limited Permit - ( PDF 19 KB)

  • Section I: Complete this section and give the form and a copy of Appendix A (PDF PDF 21 KB) to your prospective supervisor. Be sure to sign and date item 9.
  • Section II: Ask your prospective supervisor to complete this section.

Return the completed form with the $70 fee to the Office of the Professions at the mailing address at the end of the form.

Child Abuse Certification of Exemption Form - ( PDF 40 KB)
This form is not for all applicants. Use this form only if you are applying for an exemption to the requirement to complete training or coursework in the identification of child abuse and maltreatment because the nature of your practice excludes contact with persons under the age of 18 and persons 18 or older with a handicapping condition who reside in a residential care school or facility.
Last Updated: October 24, 2018