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- 491 Intern Registration (Florida Department of Health)

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DH‐MQA1175,Revised8/2020,Rule64B4‐3.0085,F.A.C. Page2of14
Upo
n receipt of your application, you will be provided a file number that identifies your application. This is not a license
number and may not be used to practice in a counseling-related field.
Select profession:
Clinical Social Work (5207) $150.00
Marri
age & Family Therapy (5208) $150.00
Mental He
alth Counseling (5209) $150.00
Fees must be paid in the form of a cashier’s check or money order, made payable to the Department of Health. The
$150.00 application fee is non-refundable.
1. PERSONAL INFORMATION
DoNotWriteinthisSpace
ForRevenueReceiptingOnly
Name: ______________________________________________________________________ Date of Birth: _______________
Last/Surname First Middle MM/DD/YYYY
Mailing Address: (The address where mail and your license should be sent)
____
____
___
________________________________________ _______ __________________________________
Street/P.O. Box Apt. No. City
____
____
___
_____________________ ________ ___________________ ________________________________
State ZIP Country Home/Cell Telephone (Input without dashes)
Practice Location: (Required if mailing address is a P.O. Box- This address will be posted on the Department of Health’s website)
___________________________________________________ _______ __________________________________
Street Apt. No. City
____
____
___
_____________________ ________ ___________________ ________________________________
State ZIP Country Work/Cell Telephone (Input without dashes)
EQUAL OPPORTUNITY DATA:
We are required to ask that you furnish the following information as part of your voluntary compliance with 41 CFR Part 60-3-
Uniform Guidelines on Employee Selection Procedure (1978); 43 FR 38295 and 38296 (August 25, 1978). This information is
gathered for statistical and reporting purposes only and does not in any way affect your candidacy for licensure.
Gender: Male Race: Native Hawaiian or Pacific Islan
der Hispanic or Latino White
Female American Indian or Alaska Native Black or African American Asian
Two or More Races
Email Notification: To be notified of the status of your application by email, check the “Yes” box and fill in your email address on the
line provided. If you choose to be notified via email you will be responsible for checking your email regularly and updating your email
address with the board office.
Yes No Email Address: ____________________________________________________
Under Florida law, email addresses are public records. If you do not want your email address released in response to a public records
request, do not provide an email address or send electronic mail to our office. Instead contact the office by phone or in writing.
Application for Registration as aAp
Registered Intern for Clinical Social Work,
Marriage & Family Therapy orer
Mental Health CounselingMe
Board of Clinical Social Work, Marriage and Familyil
Therapy, and Mental Health Counseling
P.O. Box 6330
Tallahassee, FL 32314-6330
Fax: (850) 413-6982
DH‐MQA1175,Revised 8/2020,Rule64B4‐3.0085,F.A.C. Page3of14
2. SOCIAL SECURITY DISCLOSURE
This information is exempt from public records disclosure.
Pursuant to Title 42 United States Code § 666(a)(13), the department is required and authorized to
collect Social Security numbers relating to applications for professional licensure. Additionally, section
(s.) 456.013(1)(a), Florida Statutes (F.S.), authorizes the collection of Social Security numbers as part
of the general licensing provisions.
Last Name: _____________________________________________________________
First Name: _____________________________________________________________
Middle Name: ___________________________________________________________
Social Security Number: __________________________________________________
(Input without dashes)
Social Security Information- * Under the Federal Privacy Act, disclosure of Social Security numbers is
voluntary unless specifically required by federal statute. In this instance, Social Security numbers are
mandatory pursuant to Title 42 United States Code § 653 and 654; and s. 456.013(1), 409.2577, and
409.2598, F.S. Social Security numbers are used to allow efficient screening of applicants and
licensees by a Title IV-D child support agency to ensure compliance with child support obligations.
Social Security numbers must also be recorded on all professional and occupational license
applications and will be used for license identification pursuant to Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 (Welfare Reform Act. 104 Pub. L. Section 317). Clarification of
the SSA process may be reviewed at www.ssa.gov or by calling 1-800-772-1213.
DH‐MQA1175,Revised 8/2020,Rule64B4‐3.0085,F.A.C. Page4of14
Name: _____________________________________________
3. APPLICANT BACKGROUND
List any other name(s) by which you have been known in the past. Attach additional sheets if necessary.
__________________________________________________________________________________________
4. DISASTER
Would you be willing to provide health services in special needs shelters or to help staff disaster medical
assistance teams during times of emergency or major disaster? Yes No
5. EDUCATION HISTORY
Complete the appropriate education worksheet for your profession, found at the back of the application.
The completed worksheet must be included with your application.
A. List all schools where you completed coursework in specific content areas to receive a master’s or doctoral
degree in the profession for which you are applying. All schools listed below must be consistent with the
schools provided on the education worksheet for your profession.
School Name Major
Degree Conferred
Date
(
MM/DD/YYYY
)
Degree Awarded
(if applicable)
Applicants must request an official transcript from the accredited educational institution(s) from which you
received your degree or have taken coursework. The transcript must be sent directly to the board office
from the registrar’s office of the institution and include a degree conferred date or it will not be
considered official. Transcripts may be sent via email if the institution can send official digital transcripts
using a secure transcript clearinghouse or parchment service. The transcript download link can be sent
directly to info@floridasmentalhealthprofessions.gov.
If the course title on your transcript does not clearly identify the content of the coursework, a course
description or syllabus will be required.
B. For clinical social work applicants only: Were you an advanced standing student? Yes No
If “Yes,” you must provide a letter on university letterhead from an official of the school which awarded your
master’s degree in social work, verifying the specific courses and number of semester hours completed at the
baccalaureate level which were used to waive or exempt completion of similar courses at the graduate level.
The following documentation is required for proof of Practicum, Internship, or Field Experience:
An official of the school (Dean, Department Chair) that awarded your graduate degree must provide a
letter on university letterhead verifying that the supervised practicum, internship, or field experience was
completed. Specific requirements for your profession can be found on the appropriate education worksheet
for your profession.
Documentation must be sent to the board office at info@floridasmentalhealthprofessio
ns.gov, or by mail to:
BoardofClinicalSocialWork,MarriageandFamilyTherapy,
andMentalHealthCounseling
4052BaldCypressWayBinC‐08
Tallahassee,FL32399‐3258
DH‐MQA1175,Revised 8/2020,Rule64B4‐3.0085,F.A.C. Page5of14
Name: _____________________________________________
Applicants educated outside the United States or Canada:
Any document in a language other than English must be translated into English by a board-approved
translation/ education evaluation service. Accepted evaluators can be found at
https://floridasmentalhealthprofessions.gov/forms/foreign-cred-evaluators.pdf.
Clinical Social Work- If you received your social work degree from a program outside the U.S. or
Canada, documentation must be received that the program was determined to be equivalent to programs
approved by the Council on Social Work Education by the International Social Work Degree Recognition
and Evaluation Service provided by the Office of Social Work Accreditation (OSWA). To contact the
OSWA, please visit www.cswe.org or call (703) 683-8080.
Marriage and Family/Mental Health Counseling- For the board to consider education completed
outside the U.S. or Canada, documentation must be received which verifies the institution at which the
education was completed was equivalent to an accredited U.S. institution and the coursework met the
content and credit hour requirement for graduate level coursework in the U.S. It is the applicant's
responsibility to obtain an evaluation from a recognized foreign equivalency determination service that
documents the acceptability of the coursework. The board office must receive an original evaluation
mailed directly from the educational evaluation service.
6. SUPERVISOR INFORMATION
List all qualified supervisor(s) who will be providing individual and/or group supervision. Attach additional sheets if
necessary.
Supervisor Name License Title Florida License Number
Year Licensed
(
YYYY
)
Each supervisor listed must submit written correspondence that states that the supervisor has agreed to p
rovide
you with supervision while you are a registered intern. Correspondence must come directly from the supervisor,
and may be sent by fax to 850-413-6982, or by email to info@floridasmentalhealthprofessions.gov.
Applications will not be deemed complete until all supervisor(s) have provided correspondence
confirming their agreement to supervise you as an intern.
DH‐MQA1175,Revised 8/2020,Rule64B4‐3.0085,F.A.C. Page6of14
Name: _____________________________________________
This information is exempt from public records disclosure.
7. HEALTH HISTORY
Physical and Mental Health Disorders Impacting Ability to Practice
A. During the last two years, have yo
u been treated for or had a recurrence of a diagnosed physical or mental
disorder that impaired or would impair your ability to practice? Yes No
B. In the last two years, have you been admitted or referred to a hospital, facility or impaired practitioner program
for treatment of a diagnosed mental or physical disorder that impaired your ability to practice? Yes No
Substance-Related Disorders Impacting Ability to Practice
C. During the last five years, have you bee
n treated for or had a recurrence of a diagnosed substance-related
(alcohol or drug) disorder that impaired or would impair your ability to practice? Yes No
D. During the last five years, were you admitted or directed into a program for the treatment of a diagnosed
substance-related (alcohol or drug) disorder or, if you were previously in such a program, did you suffer a
relapse? Yes No
E. During the last five years, have you been enrolled in, required to enter, or participated in any substance-
related (alcohol or drug) recovery program or impaired practitioner program for treatment of drug or alcohol
abuse? Yes No
If a “Yes” response was provided to any of the questions in this section, provide the following documents
directly to the board office:
A letter from a Licensed Health Care Practitioner, who is qualified by skill and training to address the
condition identified, which explains the impact the condition may have on the ability to practice the
profession with reasonable skill and safety. The letter must specify that the applicant is safe to practice
the profession without restrictions or specifically indicate the restrictions that are necessary.
Documentation provided must be dated within one year of the application date.
A written self-explanation, identifying the medical condition(s) or occurrence(s); and current status.
DH‐MQA1175,Revised 8/2020,Rule64B4‐3.0085,F.A.C. Page7of14
Name: _____________________________________________
8. DISCIPLINE HISTORY
A. Have you ever been denied a psychotherapy or counseling-related license or the renewal thereof in any
state? Yes No
B. Have you ever been denied the right to take a psychotherapy or counseling-related licensure examination?
Yes No
C. Have you ever had a license to practice any profession revoked, suspended, or otherwise acted against in a
disciplinary proceeding in any state? Yes No
D. Is there currently pending, in any jurisdiction, a complaint or investigation against your professional conduct or
competency? Yes No
E. Have you ever been involved in, reprimanded for or disciplined by an employer or educational institution for
misconduct including fraud, misrepresentation, academic misconduct, theft or sexual harassment?
Yes No
If you responded “Yes” to any of the questions in this section, complete the following:
Name of Agency State
Action Date
(MM/DD/YYYY)
Final Action
Under
Appeal?
Y N
Y N
Y N
Y N
If you responded “Yes” to any of the questions in this section, you must provide the following:
A written self-explanation, describing in detail the circu
mstances surrounding the disciplinary action.
A copy of the Administrative Co
mplaint and Final Order.
9. CRIMINAL HISTORY
Have you ever been convicted of, or entered a plea of guilty, nolo contendere, or
no contest to any crime in any
jurisdiction other than a minor traffic offense? You must include all misdemeanors and felonies, even if
adjudication was withheld.
Reckless driving, driving while license suspended or revoked (DWSLR), driving unde
r the influence (DUI) or
driving while impaired (DWI) are not minor traffic offenses for purposes of this question. Yes No
If you responded “Yes,” complete the
following:
Offense Jurisdiction
Date
(MM/DD/YYYY)
Final Disposition
Under
Appeal?
Y N
Y N
Y N
If you responded “Yes” in this section, you must provide the following:
A written self-explanation, describing in detail the circu
mstances surrounding each offense; including
dates, city and state, charges and final results.
Final Dispositions and Arrest Records for all offenses. The Clerk of the Court i
n the arresting
jurisdiction will provide you with these documents. Unavailability of these documents must come in the
form of a letter from the Clerk of the Court.
Completion of Sentence Documents. You may obtain do
cuments from the Department of Corrections.
The report must include the start date, end date, and that the conditions were met.
DH‐MQA1175,Revised 8/2020,Rule64B4‐3.0085,F.A.C. Page8of14
Name: _____________________________________________
10. CRIMINAL AND MEDICAID/MEDICARE FRAUD QUESTIONS
1. Have you been convicted of, or entered a plea of guilty or nolo contendere, regardless of adjudication, to a
felony under chapter (ch.) 409, F.S. (relating to social and economic assistance), ch. 817, F.S. (relating to
fraudulent practices), ch. 893, F.S. (relating to drug abuse prevention and control), or a similar felony
offense(s) in another state or jurisdiction? Yes No
If you responded “No” to the question above, skip to question 2.
a. If “Yes” to 1, for the felonies of the first or second degree, has it been more than 15 years from the date of
the plea, sentence, and completion of any subsequent probation? Yes No
b. If “Yes” to 1, for the felonies of the third degree, has it been more than ten years from the date of the plea,
sentence, and completion of subsequent probation (this question does not apply to felonies of the third
degree under s. 893.13(6)(a), F.S.)? Yes No
c. If “Yes” to 1, for the felonies of the third degree under s. 893.13(6)(a), F.S., has it been more than five
years from the date of the plea, sentence, and completion of any subsequent probation? Yes No
d. If “Yes” to 1, have you successfully completed a drug court program that resulted in the plea for the felony
offense being withdrawn or the charges dismissed (if “Yes,” provide supporting documentation)?
Yes No
2. Have you been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, to a
felony under 21 U.S.C. ss. 801-970 or 42 U.S.C. ss. 1395-1396 (relating to public health, welfare, Medicare
and Medicaid issues)? Yes No
If you responded “No” to the question above, skip to question 3.
a. If “Yes” to 2, has it been more than 15 years before the date of application since the sentence and any
subsequent period of probation for such conviction or plea ended? Yes No
3. Have you ever been terminated for cause from the Florida Medicaid Program pursuant to s. 409.913, F.S.?
Yes No
If you responded “No” to the question above, skip to question 4.
a. If you have been terminated but reinstated, have you been in good standing with the Florida Medicaid
Program for the most recent five years? Yes No
4. Have you ever been terminated for cause, pursuant to the appeals procedures established by the state, from
any other state Medicaid program? Yes No
If you responded “No” to the question above, skip to question 5.
a. Have you been in good standing with a state Medicaid program for the most recent five years?
Yes No
b. Did termination occur at least 20 years before the date of this application? Yes No
IMPORTANT NOTICE: Applicants for licensure, certification, or registration and candidates for examination may be
excluded from licensure, certification, or registration if their felony convictions fall into certain timeframes as
established in s. 456.0635(2), F.S.
DH‐MQA1175,Revised 8/2020,Rule64B4‐3.0085,F.A.C. Page9of14
Name: _____________________________________________
5. Are you currently listed on the United States Department of Health and Human Services’ Office of the
Inspector General’s List of Excluded Individuals and Entities (LEIE)? Yes No
a. If you responded “Yes” to the question above, are you listed because you defaulted or are delinquent
on a student loan? Yes No
b. If you responded “Yes” to question 5.a., is the student loan default or delinquency the only reason you
Yes
are listed on the LEIE? No
If you responded “Yes” to any of the questions in this section, you must provide the following:
Documentation for sections 7, 8, 9 and 10 must be sent to the board office at
info@floridasmentalhealthprofessions.gov, or by mail to:
BoardofClinicalSocialWork,MarriageandFamilyTherapy,
andMentalHealthCounseling
4052BaldCypressWayBinC‐08
Tallahassee,FL32399‐3258
11. APPLICANT SIGNATURE
I, the undersigned, state that I am the person identified in this application for licensure in the state of Florida.
I understand that providing false information may result in disc
iplinary action against my license or criminal penalties
pursuant to s. 456.067, F.S.
I acknowledge that Florida law requires me to immediately inform the board of any material change in any
circumstances or condition stated in the application which takes place between the initial filing and the final granting or
denial of the license and to supplement the information on this application as needed.
I acknowledge that I have read the regulations in ch. 491, F.S., and related rules. I unders
tand that I am under a
continuing obligation to keep informed of any changes to ch. 491, F.S., and related rules.
Section 456.013(1)(a), F.S., provides that an incomplete application shall expire one year after the initial filing with the
department.
Applicant Signature ____________________________________________________ Date ________________
You may print this application and sign it or sign digitally. MM/DD/YYYY
A written explanation for each question including the county and state of each termination or
conviction, date of each termination or conviction, and copies of supporting documentation.
Supporting documentation including court dispositions or agency orders
where applicable.
click to sign
signature
click to edit
DH‐MQA1175,Revised 8/2020,Rule64B4‐3.0085,F.A.C. Page10of14
BoardofClinicalSocialWork,MarriageandFamilyTherapy,
andMentalHealthCounseling
CLINICALSOCIALWORK
EDUCATIONWORKSHEETFORINTERN
Name: _____________
________________________________
1. GENERAL
INFORMATION
You are required to complete 24 semester hours or 32 quarter hou
rs of graduate level coursework in theory of human
behavior, and practice methods as courses in clinically oriented services within an accredited school of social work
program. (Only one research course may be counted towards the coursework requirement). Do not list fieldwork.
Course numbers and titles should be listed as they appear on your official transcripts. You must submit a course
description photocopied from a school catalog, or a course syllabus for all courses listed below.
If you were admitted to an advanced standing program, an official of the school whic
h awarded your master’s degree
in social work must provide a letter on university letterhead, verifying the specific courses completed at the
baccalaureate level which were used to waive or exempt completion of similar courses at the graduate level.
School Name Course Number Course Title Credit Hours
2. PSYCHOPATHOLOGY
List the graduate level psychopathology course you completed within an accred
ited school of social work program.
You must submit a course description photocopied from a school catalog, or a course syllabus for the course listed.
School Name Course Number Course Title Credit Hours
3. ADVANCED SUPERVISED FIELD PLACEMENT
You are required to complete a supervised field placement which was pa
rt of your advanced concentration in direct
practice, during which you provided clinical services directly to clients. An official of the school (Dean, Department
Chair) which awarded your graduate degree must provide a letter on university letterhead verifying:
1. that the supervised field placement was completed during the master’s or doctorate program; and
2. the setting in which you
provided clinical services direc
tly to clients.
School Name Course Number
Advanced Supervised Field
Placement Course Title
Field Placement Dates:
From-To (MM/DD/YYYY)
to
Submit worksheet with your application.
DH‐MQA1175,Revised 8/2020,Rule64B4‐3.0085,F.A.C. Page11of14
BoardofClinicalSocialWork,MarriageandFamilyTherapy,
andMentalHealthCounseling
MARRIAGEANDFAMILYTHERAPY
EDUCATIONWORKSHEETFORINTERN
Page1of2
Name: _____________________________________________
If you graduated from a program accredited by the Commission on Accreditation for Marriage and Family Therapy
Education (COAMFTE), check the box verifying your degree. You will not be required to verify your coursework.
I graduated from a COAMFTE accredited program.
If you graduated from a counseling program accredited by the Council for Accreditation of Counseling and Related
Education Programs (CACREP), complete the coursework information below.
1. COURSEWORK VERIFICATION
You must indicate the graduate level co
urse(s) you completed that satisfy the educational requirement in the content
areas listed. Course numbers and titles should be listed as they appear on your official transcripts. If the course title
on your transcript does not clearly identify the content of the coursework, a course description or syllabus may be
required.
Each of the following content areas must have a minimum of three semester hours or four quarter hours in
graduate level coursewo
rk.
Content Area School Name
Course
Number
Course Title
Credit
Hours
Dynamics of Marriage and
Family Systems
1.
2.
Marriage Therapy and
Counseling Theory and
Techniques
1.
2.
Family Therapy and
Counseling Theory and
Techniques
1.
2.
Individual Human
Development Theories
Throughout the Life Cycle
1.
2.
Personality Theory or
General Counseling
Theory and Techniques
1.
2.
Psychopathology
1.
2.
Human Sexuality Theory
and Counseling
Techniques
1.
2.
Psychosocial Theory
1.
2.
Substance Abuse Theory
and Counseling
Techniques
1.
2.
DH‐MQA1175,Revised 8/2020,Rule64B4‐3.0085,F.A.C. Page12of14
BoardofClinicalSocialWork,MarriageandFamilyTherapy,
andMentalHealthCounseling
MARRIAGEANDFAMILYTHERAPY
EDUCATIONWORKSHEETFORINTERN
Page2of2
Name: _____________________________________________
The following courses must be a minimum of one graduate-level course of three semester hours or
four quarter hours.
Content Area School Name
Course
Numbe
r
Course Title
Credit
Hours
Legal, Ethical, Professional Standards
Issues in the Practice of Marriage &
Famil
y
Therap
y
Diagnosis, Appraisal, Assessment, and
Testing for Individual or Interpersonal
Disorder or D
y
sfunction
Behavioral Research (Course must
focus on the interpretation and
application of research data as it
applies to clinical practice)
Submit worksheet with your application.
DH‐MQA1175,Revised 8/2020,Rule64B4‐3.0085,F.A.C. Page13of14
BoardofClinicalSocialWork,MarriageandFamilyTherapy,
andMentalHealthCounseling
MENTALHEALTHCOUNSELING
EDUCATIONWORKSHEETFORINTERN
Page1of2
Name: _____________________________________________
If the program you gr
aduated from was not accredited by the Council for Accreditation of Counseling and Related
Education Programs (CACREP) or if the program you graduated from was a CACREP accredited program that was not
mental health counseling, then sections 1, 2, and 3 apply to you. (There are CACREP accredited programs in
community counseling; marital, couple, and family counseling; and school counseling, for example.) If you graduated from
a CACREP clinical mental health counseling/mental health counseling program, then only section 4 applies to you.
1. GENERAL INFORMATION
Your overall degree program must be a minimum of 60 semester
hours or 80 quarter hours. Within the degree
program, you will be required to complete three semester hours or four quarter hours of individualized graduate level
coursework at an accredited educational institution in each of the content areas listed below. Course numbers and
titles should be listed as they appear on your official transcripts. If the course title on your transcript does not
clearly identify the content of the coursework, a course description or syllabus will be required.
2. COURSEWORK VERIFICATION
You must indicate below th
e graduate level course you completed that satisfies the edu
cation requirement in the
specific content area. You must have a minimum of three semester hours or four quarter hours to satisfy each
content area. To qualify for mental health counseling intern registration, you must have completed a minimum of
seven of the required course content areas below, one of which must be a course in psychopathology or abnormal
psychology. Refer to Section 491.005(4).
Content Area School Name
Course
Numbe
r
Course Title
Credit
Hours
Counseling Theories
and Practice
Human Growth
and Development
Diagnosis and Treatment
of Psychopathology
Human Sexuality
Group Theories
and Practice
Individual Evaluation
and Assessment
Career and Lifestyle
Assessment
Research and Program
Evaluation
Social and Cultural
Foundations
Substance Abuse
Legal, Ethical &
Professional Standards
Page14of14
BoardofClinicalSocialWork,MarriageandFamilyTherapy,
andMentalHealthCounseling
MENTALHEALTHCOUNSELING
EDUCATIONWORKSHEETFORINTERN
Page2of2
Name: _____________________________________________
3. UNIVERSITY-SPONSORED SUPERVISE
D CLINICAL PRACTICUM, INTERNSHIP OR FIELD EXPERIENCE
You must complete at least 700 hours of universit
y-sponsored supervised clinical practicum, internship, or field
experience that includes at least 280 hours of direct clinical services as required in the accrediting standards of
CACREP for mental health counseling programs.
If you completed fewer than 700 practicum/internship hours in your master’
s program, this requirement may be met
outside the university setting by completing supervised practice experience that meets the CACREP standards below
and is under the supervision of a qualified supervisor or equivalent.
Document non-university experience on the Graduate-Level Practicum, Internship, or Field Experience Verification
Form for M
ental Health Counseling found at https://floridasmentalhealthprofessions.gov/forms/mhc-graduate-
practicum-form.pdf. You cannot begin your post-master’s supervision experience until you meet the 700 hours of
practicum/internship requirement. The accrediting standards of CACREP for these hours are:
At least 280 of these hours must be in direct service
with actual clients that contributes to the development of
counseling skills, including experience leading groups.
An average of one hour per week of individual and/or triadic supervision.
The opportunity to become familiar with a vari
ety of professional activities and resources in addition to direct
service (e.g., record ke
eping, assessment instruments, supervision, referral, staff meetings, etc.).
The opportunity to develop prog
ram-appropriate audio/video recordings for use in supervision or to receive
live supervision of the applicant’s interactions with clients.
Evaluation of counseling performa
nce throughout the practicum/internship, including a formal evaluation
after the completion of the practicum/internship hours.
An official of the school (Dean, Department Chair) which awarded your gradu
ate degree must provide a letter on
university letterhead verifying that the supervised practicum/internship was completed in accordance with CACREP
standards. The practicum letter should also include the following:
a. Course Title(s) of Practicum/Internship/Field Experience
b. Course Number(s)
c.
School or Site Where Experience was Completed
d. Dates of Practicum/Internship or Field Experience
e. Total Number of Clock Hours Completed
f. Total Number of Direct Client Service Hours Completed
4. GRADUATE OF A CACREP MENTAL HEALTH COUNSELING PROGRAM
If you graduated from a mental health counseling program accred
ited by CACREP, your overall degree program
must be a minimum of 60 semester hours or 80 quarter hours, including a course in human sexuality and a course
in substance abuse.
Indicate below the graduate level course you completed that satisfies the two specific content areas.
You must have a minimum
of three semester hours or four quarter hours in each content area.
Content Area School Name
Course
Numbe
r
Course Title
Credit
Hours
Human Sexuality
Substance Abuse
DH‐MQA1175,Revised 8/2020,Rule64B4‐3.0085,F.A.C.
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Completed 27 November 2021

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