Fillable - 491 Licensure By Endorsement (Florida Department of Health)

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- 491 Licensure By Endorsement (Florida Department of Health)

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Are you an active duty member of the United States
Armed Services?
Are you a veteran of the United States
Armed Services?
Are you
the
spouse of a veteran of the United States
Armed Services?
Are you the spouse of an active member of the United States
Armed Services?
If you answered “Yes” to any of these questions, you may qualify for a reduction in
Health’s commitment to serving members and veterans of the United States Armed
Forces and their families online at
L I IC E N N G
S
FOR C E S
A
R
M
E
D
DH‐MQA5048,Revised8/2020,Rule64B4‐3.001,F.A.C. Page3of12
Applicants must hold a valid, current license in another state in the specific profession identified for licensure and have
actively practiced in that profession for at least three of the past five years. If you do not meet both the licensure and
practice requirements you are ineligible to apply by endorsement and must apply by examination.
Select profession:
Clinical Social Work (5201) $180.00
Marriage & Family Therapy (5202) $180.00
Mental Health Counseling (5203) $180.00
1. PERSONAL INFORMATION
Application for Licensure as a Clinical
Social Worker, Marriage & Family Therapist
or Mental Health Counselor by Endorsement
Board of Clinical Social Work, Marriage and Family
Therapy, and Mental Health Counseling
P.O. Box 6330
Tallahassee, FL 32314-6330
Fax: (850) 413-6982
Email: info@floridasmentalhealthprofessions.gov
DoNotWriteinthisSpace
ForRevenueReceiptingOnly
Name: _____________________________________________________________________ Date of Birth: ________________
Last/Surname First Middle MM/DD/YYYY
Mailing Address: (T
he 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: (Requir
ed if mailing address is a P.O. Box- This address will be posted on the Department of Health’s website)
___________________________________________________ _______ __________________________________
Street Suite No. City
____
____________________________ ________ ___________________ ________________________________
State ZIP Country Work/Cell Telephone (Input without dashes)
EQUAL OPPORTUNITY DATA:
W
e 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 Pac
ific Islander 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.
Total fee of $180.00 includes the following:
Application Fee $100.00
Initial Licensure Fee $75.00
Unlicensed Activity Fee $5.00
Fees must be paid in the form of a cashier’s check or money order, made payable to the Department of Health. An applicant
who is denied licensure or withdraws their application is entitled to a $80.00 (Initial Licensure Fee and Unlicensed Activity
Fee) refund. Requests to withdraw or for a refund must be made in writing. Fees are refundable for up to three years from
the date of receipt.
DH‐MQA5048,Revised 8/2020,Rule64B4‐3.001,F.A.C. Page4of12
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‐MQA5048,Revised 8/2020,Rule64B4‐3.001,F.A.C. Page5of12
Name: _____________________________________________
3. APPLICANT BACKGROUND
A. List any other name(s) by which you have been known in the past. Attach additional sheets if necessary.
__________________________________________________________________________________________
B. Do you hold a valid, current license in another state in the profession for which you are applying, and actively
practiced in such capacity for at least three of the past five years? Yes No
If “No,” you are ineligible to apply by endorsement.
C. List the active license in the profession for which you are applying from the state(s) in which you have
actively practiced for three of the past five years.
License
Type
License # State/Country
Original Date
Issued
(
MM/DD/YYYY
)
Expiration
Date
(
MM/DD/YYYY
)
Status of License
D. Do you hold, or have you ever held a license to practice any counseling-related professions o
r any other
health-related license(s), other than the license(s) listed above? Yes No
E. List all health-related licenses (active, inactive or lapsed), other than the license(s) listed above.
License
Type
License # State/Country
Original Date
Issued
(
MM/DD/YYYY
)
Expiration
Date
(
MM/DD/YYYY
)
Status of License
Submit a License Verification form to ALL state(s) of licensure. License verificati
ons must be received directly
from the licensing authority regardless of the status of the license. A copy of your license will not be accepted
in lieu of official verification from the licensing agency.
F. Do you have any applications for licensure in a counseling-related profession currently pending in any state
(including Florida), U.S. territory, or foreign country? Yes No
G. List all pending applications for licensure in a counseling-related profession.
License Type State/Country
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 m
ajor disaster? Yes No
DH‐MQA5048,Revised 8/2020,Rule64B4‐3.001,F.A.C. Page6of12
Name: _____________________________________________
5. EDUCATION HISTORY
The following continuing education courses are required for licensure:
A. Have you completed the required 8-hour Florida Laws and Rules course? Yes No
__________________________________________ __________________________ ___________________
Florida Laws and Rules Course
Title Provider Name Date Completed
(MM/DD/YYYY)
B. Have you completed the required 3-hour HIV/AIDS course? Yes No
__________________________________________ __________________________ ___________________
HIV/AIDS Course Ti
tle Provider Name Date Completed
(MM/DD/YYYY)
If you have not completed the 3-hour HIV/AIDS course, you may submit the HIV/AIDS Affidavit found at the back
of this application, attesting you will complete the course within six months. Board-approved providers and
courses can be found at www.cebroker.com.
Documentation must be sent to the board office at info@floridasmentalhealthprofessions.gov, or by mail to:
BoardofClinicalSocialWork,MarriageandFamilyTherapy,
andMentalHealthCounseling
4052BaldCypressWayBinC‐08
Tallahassee,FL32399‐3258
6. EXAMINATION HISTORY
For inform
ation regarding application deadlines, examination approval, and exa
mination dates, visit
floridasmentalhealthprofessions.gov/resources/exam-schedule/.
Have you passed the national clinical examination for the profession in which you are applying? Yes No
If “Yes,” provide the exam name: ____________________________________ Date passed: ______________
MM/DD/YYYY
If you have passed the national clinical examination for your profession and did not take the examination
as a Florida-registered intern, you must request an official score report to be sent directly to the board
office. Scores are only accepted from other state boards and the following:
Licensed Clinical Social Worker scores accepted from the Asso
ciation of Social Work Boards (ASWB).
Licensed Marriage and Family Therapist scores accepted from the Association of Marital and Family Therapy
Regulatory Boards (AMFTRB).
Licensed Mental Health Counselor scores accepted from the National Board of Certified Cou
nselors (NBCC).
Applicants requiring special testing accommodations:
Licensed Clinical Social Work candidates requiring special accomm
odations must contact the Association of
Social Work Boards (ASWB) directly to arrange testing accommodations. Contact ASWB at 1-800-225-6880 or
http://www.aswb.org.
Licensed Marriage and Family Therapy candidates requiring special accommodations must submit an
application for special testing accommodations no later than 60 days prior to sitting for the
examination to the Professional Testing Corporation (PTC). You must submit your request using the
Request for Special Needs Accommodations Form found online at
http://www.ptcny.com/PDF/PTC_SpecialAccommodationRequestForm.pdf. You may reach the PTC by phone at
212-356-0660.
Licensed Mental Health Counseling candidates requiring spec
ial accommodations must submit a request form to
the National Board for Certified Counselors (NBCC). A Computer-Based Testing Special Accommodations
Request form is located in the NCMHCE Candidate Handbook, which can be downloaded at the NBCC website at
www.nbcc.org.
DH‐MQA5048,Revised 7/2020,Rule64B4‐3.001,F.A.C. Page7of12
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 you been treated for or had a recurrence of a diagno
sed 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 been treated for or had a recurrence of a diagnose
d 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‐MQA5048,Revised 8/2020,Rule64B4‐3.001,F.A.C. Page8of12
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 ci
rcumstances surrounding the disciplinary action.
A copy of the Administrati
ve Complaint and Final Order.
9. CRIMINAL HISTORY
Have you ever been convicted of, or entered a plea of guilty, nolo contendere, o
r 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), drivin
g under 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 th
e 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 ci
rcumstances 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 in 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 ob
tain documents from the Department of Corrections.
The report must include the start date, end date, and that the conditions were met.
DH‐MQA5048,Revised 8/2020,Rule64B4‐3.001,F.A.C. Page9of12
Name: _____________________________________________
10. CRIMINAL AND MEDICAID/MEDICARE FRAUD QUESTIONS
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.
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
DH‐MQA5048,Revised 8/2020,Rule64B4‐3.001,F.A.C. Page10of12
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
are listed on the LEIE? Yes No
If you responded “Yes” to any of the questions in this section, you must provide the following:
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.
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 rec
ognize that providing false information may result in disciplinary action against my license or criminal penalties
pursuant to s. 456.067, F.S.
I understand 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 hereby acknowledge that I have read the regulations in ch. 491, F.S., and related rules. I understand
that I am under a continuing obligation to keep informed of any changes to ch. 491, F.S., and related
rules. I further state that I will comply with all requirements for licensure renewal, including continuing education
credits.
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
DH‐MQA5048,Revised 8/2020,Rule64B4‐3.001,F.A.C. Page11of12
Complete verifications must be mailed directly from the licensing agency to:
BoardofClinicalSocialWork,MarriageandFamilyTherapy,
andMentalHealthCounseling
4052BaldCypressWayBinC‐08
Tallahassee,FL32399‐3258
License/CertificationVerificationRequest
Part I: To be completed by applicant (Florida requires verification of all your current and previously held
licenses.)
Name: ____________________________________________________________________________________
Address: __________________________________________________________________________________
Name original license was issued under: _________________________________________________________
License Number: _____________________________________ State: _________________________________
I hereby authorize release of any information regarding my licensure status to the Florida Board of Clinical Social
Work, Marriage and Family Therapy, and Mental Health Counseling.
Applicant Signature: _________________________________________________ Date: __________________
MM/DD/YYYY
Part II: To be completed by state licensing agency
All verifications must be in English a
nd include the following criteria:
*
Typed on an official state form or letterhead
*
Include an official board seal
*
Signature and title of state board official
The following information must be included in all verifications:
*
Licensee name * License number * State or jurisdiction of licensure
*
Licensure status * Is license in good standing?
*
Date of issuance and expiration
*
Licensure method (examination, grandfathering, reciprocity/endorsement) If exam, provide exam
name, exam level, exam date, and score achieved.
*
Has this license ever been encumbered (denied, revoked, suspended, surrendered, limited, placed
on probation)?
*
If this license has ever been encumbered, please provide certified copies of documentation
regarding the action with the completed license verification.
DH‐MQA5048,Revised 8/2020,Rule64B4‐3.001,F.A.C. Page12of12
BoardofClinicalSocialWork,MarriageandFamilyTherapy,
andMentalHealthCounseling
HIV/AIDSAFFIDAVIT
Pursuant to s. 491.0065, F.S., and Rule 64B4-8.002, Florida Administrative Code, all initial
licensure applicants are required to complete an approved education course on human
immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS). The course
must provide a minimum of three hours of HIV/AIDS education, including education on protocols
and procedures applicable to HIV counseling, testing, reporting and partner notification.
An applicant who has not taken the course at the time of licensure shall, upon submission of an affidavit showing good
cause, be allowed six months to complete this requirement. If you have already completed this course, please send proof
with your application. If you have not yet completed the course, please fill out this affidavit, have it notarized, and return
with your application.
Your application is incomplete without this affidavit or proof of completion of the HIV/AIDS course.
APPLICANT AFFIRMATION
I, _______________________________________, am of legal age and have personal knowledge of the matters stated in
(Applicant Full Name)
this affidavit. I will complete an approved course which provides a minimum of three hours of HIV/AIDS education within
the first six months of my licensure by the Department of Health.
Applicant Signature ____________________________________________________ Date ___________________
MM/DD/YYYY
NOTARY SIGNATURE
Before me, the undersigned authority, personally appeared ________________________________________ who
(Applicant Full Name)
deposes and affirms the above statement is true and correct.
State of ________________ County of ______________
Sworn to and/or subscribed before me this _______________ day of _______________________, 20___________
By _____________________________________________ whose identity is known to me by __________________
Notary Signature ________________________________ Printed Name of Notary _______________________________
[NOTARY SEAL]
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- 491 Licensure By Endorsement (Florida Department of Health)

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Completed 27 January 2022

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