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Form 4F - Certification of Licensed Experience

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 9.
  • 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).

Electronic Verification of Experience

The Office of the Professions (OP) will accept experience forms directly from supervisors provided that:

  • OP can independently verify that the documentation is received directly from the supervisor
  • The applicant had no opportunity to directly alter the experience form before it is sent or transmitted.
  • Any experience documentation submissions should be made electronically to DPLSExperience@nysed.gov*.

*Do NOT use this email to submit a question, as we will be unable to provide a response. Submit a Contact Us Form for questions regarding specific applications or to check the status of a licensure application.