This form is not for all applicants. Use this form ONLY if you are applying/have applied for a New York State Limited Permit as a Mental Health Counselor online.
- Section I: Complete this section. Give your supervisor a copy of Appendix A and have them complete Section II.
- Section II: Your supervisor must complete this section before you can submit it to the Office of the Professions at the appropriate address at the end of the form. It is your responsibility to ensure your supervisor fully completes Section II. Failure to complete this form will delay its review.
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