Fillable ***FOR OFFICE USE ONLY*** Signature of Board Administrator (State of Rhode Island)

Fill Online, Printable, Fillable, Blank ***FOR OFFICE USE ONLY*** Signature of Board Administrator (State of Rhode Island) Form

Use Fill to complete blank online STATE OF RHODE ISLAND pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

***FOR OFFICE USE ONLY*** Signature of Board Administrator (State of Rhode Island)

On average this form takes 32 minutes to complete

The ***FOR OFFICE USE ONLY*** Signature of Board Administrator (State of Rhode Island) form is 8 pages long and contains:

  • 0 signatures
  • 12 check-boxes
  • 123 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your State of Rhode Island forms online.

BROWSE STATE OF RHODE ISLAND FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Rhode Island
Board of Mental Health Counselors and
Marriage & Family Therapists
Room 104
3 Capitol Hill
Providence, RI 02908-5097
Instructions and Application For
License As A
Phone: (401) 222-2828 Fax: (401) 222-1272TTY/TDD: (800) 745-5555
Examination
Endorsement
(From Another State)
Mental Health Counselor
by
***FOR OFFICE USE ONLY***
Receipt #:
Application Approved:
License Number:
Issue Date:
Signature of Board Administrator
ID#:
Revised 11/01/2018 jcp
License #
Name
Mental Health Couns. Checklist
Endorsement Examination
App. & Fee
Date:__________ Check______
Transcript
Statements of Supervised Practice
Supervisor’s Resume(s)
Verication of Supervisor’s OOS Lic.
Score/Certication from NBCC
License Verif. from Other State(s)
***FOR OFFICE USE ONLY***
Have you already taken the NCMHCE or NCE Exams through the NBCC?
Yes No
Applicant - Print Name
LAST NAME FIRST NAME MI
I am the spouse of someone in active military duty or the spouse of a reservist
I am a military veteran with honorable discharge
I am in active military duty or a reservist
MILITARY STATUS ELIGIBILITY
Please check ONE of the following criteria for expedited application:
(Documentation Required)
see next page for instructions
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 2
LICENSURE REQUIREMENTS
Completed Application with Cover Page - Applications are valid for 1 year from the day they are received at RIDOH.
If you are not licensed within the year you must submit a new application.
Check or money order (preferred), made payable (in U.S. funds only) to the RI General Treasurer in the amount
of $70.00 and attached to the upper left-hand corner of the rst (Top) page of the application. THIS APPLICATION
FEE IS NONREFUNDABLE. Please be advised that this is an application fee and includes the rst license only up
until the next expiration date. All Marriage and Family Therapist licenses expire biennally on July 1st of the even
numbered years.
Ocial transcript(s), with registrar’s signature and school seal from an accredited College or University (60 credits
required). CACREP Accreditation, if applicable No student copies will be accepted.
Score/Certication NCMHCE sent directly from the NBCC - Telephone 1-336-547-0607) (pertains only to applicants
who have previously sat for the national exam).
Statement(s) of Supervised Practice - These hours are to be accrued after 60 credits are completed. (including su-
pervisor’s resume) (Form included in this application to be used for that purpose) If you are applying for the MHC
license by endorsement and your original practice supervisor is no longer available to complete the RI Statement
of Supervised Practice form, please have your original state of licensure send a copy of your original supervised
practice form from your original license or have the state verify your supervision and submit in a sealed envelope.
If you have ever been licensed in another state, license verication(s) must be sent directly from the state(s) in
which you hold or have held a license. (Interstate Verication Form included in this application can be used for that
purpose)
If applying for expedited military status you must include one of the following: Leave Earning Statement (LES), Let-
ter from Command, Copy of Orders or DD-214 showing honorable discharge.
Examination Information
The exam required for licensure is the National Clinical Mental Health Counselor Exam (NCMHCE). The National Board
of Certied Counselors (NBCC) is the national certication agency, which owns/administers this exam. Upon receipt of
your completed license application, HEALTH will register you with NBCC for the next scheduled exam. You will receive
notication of exam admittance, location, directions, etc. from NBCC approximately ten (10) days prior to the exam date.
NBCC sends exam results to HEALTH (not individual applicants) in approximately six (6) weeks. HEALTH will then
forward your exam results to you.
For exam information, including exam dates, the preparation guide and other study materials, please refer to the NBCC
website:
http://www.nbcc.org
Licensure Information
Please visit the RIDOH website at http://www.health.ri.gov/licenses to Verify your license, download Rules
and Regualtions/Laws for your profession, download change of address forms, other licensing forms or obtain
our contact information. HEALTH will not, for any reason, accelerate the processing of one applicant at the ex
pense of others.
License Certicates
RIDOH will be providing wallet license cards ONLY on issuance of licenses. If you wish to receive a license cer-
ticate, suitable for framing, please check the box below and attach a separate check in the amount of $30.00
made payable to RI General Treasurer.
I would like to receive a license certicate. I have enclosed a separate check in the amount of $30.00
State of Rhode Island
Board of Mental Health Counselors and Family & Marriage Therapists
Application for License as a Mental Health Counselor
Refer to the Application Instructions when completing these forms. Type or block print only. Do not use felt-tip pens.
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 3
1. Name(s)
Maiden, if applicable
Sux (i.e., Jr., Sr., II, III)
Name(s) under which originally licensed in another state, if dierent from above (First, Middle, Last).
2. Social Security
Number
3. Gender
4. Date of Birth
FemaleMale
U.S. Social Security Number
Title (i.e., Mr., Mrs., Ms., etc.)
Surname, (Last Name)
Middle Name
First Name
Month
Day Year
5. Home
Address
1st Line Address (Apartment/Suite/Room Number, etc.)
Second Line Address (Number and Street)
City
Country, If NOT U.S.
This is the name that
will be printed on your
License/Permit/Cer-
ticate and reported
to those who inquire
about your License/
Permit/Certicate. Do
not use nicknames, etc.
1st Line Address (Department/Suite/Room Number, etc.)
Name of Business/Work Location
Second Line Address (Number and Street)
City
Country, If NOT U.S.
1 9
It is your responsibility
to notify the board of all
address changes.
State
Zip Code
Postal Code, If NOT U.S.
Business FaxExtension
Business Phone
Home Phone
Home Fax
Email Address (Format for email address is Username@domain e.g. applicant@isp.com)
Postal Code, If NOT U.S.
State
Zip Code
6. Business
Address
(ONLY if it is
RELATED to
your license.)
It is your responsibility
to notify the board of all
address changes.
This address will
appear on the De-
partment of Health
web site.
“Pursuant to Title 5, Chapter 76, of the Rhode Island General Laws, as
amended, I attest that I have led all applicable tax returns and paid all
taxes owed to the State of Rhode Island, and I understand that my Social
Security Number (SSN) will be transmitted to the Divison of Taxation to
verify that no taxes are owed to the State.”
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 4
7. Preferred
Mailing
Address
Please check ONE
Please use my Home Address as my preferred mailing address
Please use my Business Address as my preferred mailing address
8a. Qualifying
Education
Please list the name
and information about
the school that you
attended that qualies
you for this license.
Applicant: Print your complete last name >
Name of School
Type of School (University, College, Technical School, etc.)
Date Graduated: Number of Credit Hours
Month
9. Other State
License(s)
Please answer the
question and list
state(s), if applicable
Have you ever held, or do you currently hold, a license in another state?
If the answer to this question is “yes”, enter all other state licenses in Question 10 (below):
10. Licensure
List all states or
countries in which
you are now, or ever
have been licensed
to practice your
profession.
State/Country: State/Country:
Inactive
Active
Inactive
Active
Inactive
Active
Inactive
Active
Inactive
Active
Inactive
Active
Inactive
Active
InactiveActive
Year
Degree Received (Bachelor of Arts, Master of Science, Diploma, etc. )
8b. Supervised
Practicum,
Internship
and Work
Experience
Requirement Location (Name and Address ) Date Date Hours
Began Completed Completed
Yes No
Please list:
Supervised
Practicum
(12 semester or 18
quarter hours)
Supervised In-
ternship
(1 calendar year of
20 hours/week)
Supervised Work
Experience (mini-
mum 2000 hours
Post-Graduate
completed in mini-
mum of 2 years)
Approved Super-
visor of Work
Experience
Include name and
address (minimum
100 hours)
(Minimum 2000
Hours of Post-
Graduate Experience
completed in
minimum of 2 yrs)
(Minimum of 100
Hrs. Post-Graduate
Supervised Casework)
(12 semester or 18
quarter hours)
(1 calendar year
of 20 hours/week)
Minimum of 600
Hours
Supervised
Practicum
Supervised
Internship
Supervised
Work
Experience
Approved
Supervisor
of Work
Experience
MINIMUM OF 60
CREDITS ARE RE-
QUIRED
After 60 Credits
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 5
Respond to the question
at the top of the section,
then list any criminal
conviction(s) in the
space provided.
If necessary, you may
continue on a separate
8½ x 11 sheet of paper.
11. Criminal
Convictions
Month Year
Abbreviation of State and Conviction
1
(e.g. CA - Illegal Possession of a Controlled Substance):
Yes No
12. Disciplinary
Questions
Check either Yes
or No for each
question.
Note: If you answer “Yes” to any question, you are required to furnish complete details, including date, place, reason and
disposition of the matter. You may use the space below or, if needed, on a separate sheet of paper.
Applicant: Print your complete last name >
Have you ever been convicted of a violation, plead Nolo Contendere, or
entered a plea bargain to any federal, state or local statute, regulation, or
ordinance or are any formal charges pending?
1. Has any Health Professional license, certicate, registration, or permit you
hold or have held, been disciplined or are formal charges pending?
2. Have you ever been denied a license, certicate, registration or permit in
any state?
Yes No
Yes No
I, ____________________________________, being rst duly sworn, depose and say that I am the person
referred to in the foregoing application and supporting documents.
I have read carefully the questions in the foregoing application and have answered them completely, without
reservations of any kind, and I declare under penalty of perjury that my answers and all statements made
by me herein are true and correct. Should I furnish any false information in this application, I hereby agree
that such act shall constitute cause for denial, suspension or revocation of my license to practice as a Mental
Health Counselor in the State of Rhode Island.
I understand that this is a continuing application and that I have an armative duty to inform the Rhode Island
Board of Mental Health Counselors and Marriage & Family Therapists of any change in the answers to these
questions after this application and this adavit is signed.
_____________________________________ _________________________________
Signature of Applicant Date of Signature (MM/DD/YY)
13. Adavit of
Applicant
Complete this section
and sign.
Make sure that you
have completed all
components accu-
rately and completely.
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 6
RI Board of Mental Health Counselors and Marriage & Family Therapists
Room 104, 3 Capitol Hill
Providence, RI 02908-5097
(401) 222-2828
STATEMENT OF SUPERVISED PRACTICE
I am applying for a license to practice as a Mental Health Counselor in the State of Rhode Island. The Rhode Island Board of Mental Health Counselors
and Marriage & Family Therapists requires that the following section be completed by my supervisor. This constitutes authority for you to release all
information in your les, favorable or otherwise, directly to the Rhode Island Board at the above address.
Print/Type Full Name
Previous Names Used
THIS SECTION TO BE COMPLETED BY THE SUPERVISOR
Substitute forms are not acceptable, copy this form as needed.
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 6
Signature Date
Date of Birth
1. What is the educational level of the supervisee?
2. Please provide the name and the nature of the setting in which the supervised practice took place.
3. Dates of practice covered in this report: Number of practice hours during this period
4. Supervisee’s duties
Number of one-to-one supervisory hours
5. Assessment of supervisee’s performance (elaborate):
CERTIFICATION: I hereby acknowledge that the above statements are true and I am willing to accept professional
responsibility for the work done by the candidate while under my supervision. I will return this completed form directly to the Board at
the above address. I will also attach a copy of my curriculum vitae to this form for review by the Board.
Signature Date
Printed Name Title
Address
License Number State in which granted Area of specialization
RI Board of Mental Health Counselors and Marriage & Family Therapists
Room 104, 3 Capitol Hill
Providence, RI 02908-5097
(401) 222-2828
CORE CURRICULUM COURSEWORK REQUIREMENT FORM
In order to qualify for Licensure you must have taken graduate credit courses and graduate work in the
following areas. Please list your courses which correspond to the given content areas. Refer to the licens-
ing regulations (Appendix A-1) for clarication of the content areas. Elective courses that do not t into the
particular areas should be noted also. If the title of the course does not clearly reect course content attach a
course description.
1. Helping Relationships
and Counseling Theory
(9 credits minimum)
2. Human Growth and
Development
(3 credits minimum)
3. Social and Cultural
Foundations
(3 credits minimum)
4. Group Counseling
(3 credits minimum)
5. Lifestyle and Career
Development
(3 credits minimum)
6. Appraisal
(3 credits minimum)
7. Research and Program
Evaluation
(3 credits minimum)
8. Professional Orientation
(3 credits minimum)
9. Electives: (Courses
may reect a specialization
area, or add knowledge &
skills in interdisciplinary
studies).
Print/Type Full Name
ALL APPLICANTS - PLEASE COMPLETE THE FOLLOWING:
Substitute forms are not acceptable, copy this form as needed.
Signature Date
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 7
Content Area Date Course Code Course Title Credit Hours
RI Board of Mental Health Counselors and Marriage & Family Therapists
Room 104, 3 Capitol Hill
Providence, RI 02908-5097
(401) 222-2828
INTERSTATE VERIFICATION FORM - OTHER STATE LICENSURE
I am applying for a license to practice as a Mental Health Counselor in the State of Rhode Island. The Rhode Island Board of Mental Health Counselors and
Marriage & Family Therapists requires that this form be completed by the jurisdiction(s) in which I hold or have held a license. This constitutes authority
for you to release all information in your les, favorable or otherwise, directly to the Rhode Island Board at the above address.
Print/Type Full Name
Previous Names Used
Please Ax
Board Seal Here
License Number Date Issued
THIS SECTION TO BE COMPLETED BY THE MENTAL HEALTH COUNSELORS BOARD
Substitute forms are not acceptable, copy this form as needed.
Certication:
______________________________________________ ___________________
Signature Date
________________________________________________________________
Type or Print Name
________________________________________________________________
Title
________________________________________________________________
Full Name of Licensing Board
Please return directly to the Board at the above address. Thank you for your prompt cooperation.
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 8
Signature Date
Social Security Number Date of Birth
Counseling/Therapy Degree Completed: Location: Graduation Date:
Licensed by Examination? Applicant has completed and passed the National Certication Exam (LCMHC):
Yes No Yes No
Active Inactive Lapsed
Original Date Issued: Expiration Date:
License Status:
If you answer “Yes” to questions 1-4, please provide a written explanation below, and attach a copy of all supporting documentation (e.g., Board order,
complaint, etc.).
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Questions:
1. Has this licensee ever been investigated by your Board? Yes No
2. Has this licensee incurred any disciplinary proceedings in your state, or is any action pending? Yes No
3. Has the applicant’s license ever been denied, surrendered, reprimanded, suspended, revoked or placed Yes No
on probation?
4. Do you know of any information that may discredit this person? Yes No
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

***FOR OFFICE USE ONLY*** Signature of Board Administrator (State of Rhode Island)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 23 April 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document