Fillable Form 861: APPLICATION FOR LICENSED ASSOCIATE COUNSELOR OF (Department of Technology and Information)

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Form 861: APPLICATION FOR LICENSED ASSOCIATE COUNSELOR OF (Department of Technology and Information)

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APPLICATION FOR LICENSED ASSOCIATE COUNSELOR OF MENTAL HEALTH
INSTRUCTION SHEET
Before completing the application for licensure as an Associate Counselor of Mental Health (LACMH), both you, as the
applicant, and your supervisor(s) should carefully read this entire instruction sheet, including the counseling experience
and supervision requirements explained below. The hours of experience and supervision are documented on the
PLANNED DIRECT SUPERVISION and PLANNED PROFESSIONAL COUNSELING EXPERIENCE forms in the application.
Associate Counselor of Mental Health
POST-MASTERS MENTAL HEALTH COUNSELING EXPERIENCE REQUIREMENTS
When applying for Licensed Associate Counselor of Mental Health (LACMH), you must provide a written plan for
acquiring the experience required in the Board’s Rules and Regulations
. Your proposed supervisor must sign the plan.
Definitions to Understand
• Professional mental health counseling is the application of clinical counseling principles, methods or procedures
including the diagnosis and treatment of mental and emotional disorders to assist individuals in achieving more
effective personal and social adjustment. (
24 Del C. § 3031(4))
• Professional direct supervision is face-to-face consultation, on a regularly scheduled basis, between a supervisee
and a Licensed Professional Counselor of Mental Health (LPCMH) or other behavioral health professional
approved by the Board. The services rendered must be consistent with the supervisee's education, training and
experience. (
24 Del C. § 3031(3))
• An acceptable clinical supervisor must have
o at least two years of practice after licensure in any jurisdiction
o no disciplinary record.
Requirements for Supervisors
If your proposed supervisor does not hold an active Professional Counselor of Mental Health license (LPCMH) in any
jurisdiction (state, U.S. Territory or District of Columbia), the Board must pre-approve the supervisor.
You may request approval from the Board for supervision by a behavioral health professional with specialty or expertise
in a clinical competency essential to your training and holds any of the following licenses in any jurisdiction:
• clinical social worker
• clinical psychologist
• physician specializing in psychiatry
• marriage and family therapists
• advanced practice registered nurses
If your proposed supervisor is not a professional licensed by the Delaware Board, the supervisor must attest that
he/she has:
• read and is familiar with the requirements for licensure in Delaware, including the applicable statutes, rules and
regulations
• the training to provide clinical supervision
Additionally, your proposed supervisor must have:
• been in practice for at least two years post-licensure with no disciplinary actions,
• completed a minimum of three hours of continuing education (CE) in clinical supervision within the past two
years or a total of twelve hours of CE in clinical supervision in a lifetime, and
• no more than ten total supervisees at any one time.
CANNON BUILDING
861
SILVER LAKE BLVD., SUITE 203
D
OVER, DELAWARE 19904-2467
STATE OF DELAWARE
BOARD OF MENTAL HEALTH AND CHEMICAL
DEPENDENCY PROFESSIONALS
TELEPHONE:
(302)
744-4500
FAX: (302) 739-2711
WEBSITE: DPR.DELAWARE.GOV
EMAIL: customerservice.dpr@state.de.us
Revised 10/2018
Associate Counselor of Mental Health
POST-MASTERS MENTAL HEALTH COUNSELING EXPERIENCE REQUIREMENTS
(continued)
The proposed supervisor will be required to provide an official verification of professional licensure from that
jurisdiction.
Certified school counselors and certified school psychologists are NOT approved clinical supervisors.
Breakdown of Hours of Counseling Experience Under Direct Supervision
You will be required to provide verification that you have completed a total of at least 1,600 hours of post-Masters
mental health counseling while under the direct supervision of one or more approved clinical supervisors.
• At least 1,500 of the 1,600 hours must be actual face-to-face direct mental health counseling services. Of the
1,500 hours, at least 750 hours must be individual face-to-face client sessions and must involve providing direct
mental health counseling services. The other 750 hours may be individual, group, couple or family counseling
services or some combination of those services.
• At least 100 hours must be face-to-face professional direct supervision with your supervisor. Face to face
supervision includes both in person and live video conferencing. Live video conferencing must not exceed 50
percent of the total 100 hours of supervision.
o Individual Direct Supervision must be one to one, face to face meetings between the you and your
supervisor. The entire 100 hour requirement may be fulfilled by individual supervision.
o Group Supervision must be face to face meetings between the supervisor and no more than six
supervisees. No more than 40 hours of group supervision shall be acceptable towards fulfillment of the 100
hour direct supervision requirement.
All of the required hours—whether or not directly supervised—must be completed in a period of not less than
two but no more than four years.
Counseling Experience Not Under Direct Supervision
Your clinical or administrative supervisor(s) must verify that you have provided additional hours of post-Masters mental
health counseling. These hours, when added to the 1,600 or more hours of direct supervision verified by your clinical
supervisor(s), must total at least 3,200 hours..
For more information about the experience requirements, refer to Sections 2.4 of the Board’s Rules and Regulations
.
Requirements for All Applications
Both you and your supervisor(s) should carefully follow the instructions for completing the forms. Incomplete or
incorrectly completed forms delay processing of the application.
• The Board will not accept a resume in lieu of or in addition to the forms.
Submit completed, signed and notarized Application for Licensed Associate Counselor of Mental Health.
• Applications that are incomplete, unsigned or not notarized will be rejected.
Enclose the non-refundable processing fee by check or money order made payable to the "State of Delaware."
• Applications not accompanied by the required fee will be rejected.
Complete the Criminal History Record Check Authorization form to request State of Delaware and Federal Bureau of
Investigation criminal background checks. Follow the instructions on the form to arrange to be fingerprinted.
Arrange for the Board office to receive verification of your National Counselor Examination scores (NCE), National
Clinical Mental Health Counseling Examination (NCMHCE), or other examination acceptable to the Board as follows:
• If you have passed the NCE or NCMHCE, follow the instructions for requesting a score report on the National
Board Certified Counselors (NBCC) website at www.nbcc.org/Exams
.
• If you have passed another exam equivalent to the NCE or NCMHCE, arrange for the organization to send your
score report directly to the Board office.
Arrange for the Board office to receive a verification of licensure from each jurisdiction (state, U.S. territory, District of
Columbia) where you now hold, or have ever held, a license to practice as a mental health professional.
Revised 10/2018
Arrange for your college/university to send an official transcript directly to the Board office.
Documentation of your coursework is needed when your graduate program of studies is not from a regionally
accredited institution of higher education or your degree is in a discipline other than clinical mental health counseling.
• If you do not have a Master's degree in clinical mental health counseling with at least 60 graduate semester hours
or an equivalent degree in clinical mental health counseling, submit the following:
o completed Evaluation of Coursework form (included with the application)
o course catalog or course descriptions
• The degree you obtained must include the following areas:
o Professional Counseling Orientation and Ethical Practice,
o Social and Cultural Diversity,
o Human Growth and Development,
o Career Development,
o Counseling and Helping Relationships,
o Group Counseling and Group Work,
o Assessment and Testing, and
o Research and Program Evaluation
Arrange for your clinical supervisor(s), under whose supervision you will complete the required hours, to complete the
form entitled
PLANNED DIRECT SUPERVISION.
Arrange for an administrative supervisor to complete the form entitled PLANNED PROFESSIONAL COUNSELING
EXPERIENCE
to verify the hours of post-Master’s professional clinical counseling experience that you will receive while
not under the direct supervision of an approved clinical supervisor. If you will have more than one period of
experience, arrange for a separate box to be completed for each period of experience.
If you have never been issued a U.S. Social Security Number (SSN), submit a Request for Exemption from Social
Security Number Requirement.
The Privacy Act of 1974, Section 7, requires the following information to be given to all applicants: Applicants for any Delaware professional or
occupational license, permit, registration or certificate (other than Gaming permits) are required to provide a U.S. SSN (29 Del. C. §8735(m)). The
Division of Professional Regulation uses the SSN primarily to verify identity and safeguard personal information. It may also be used to enforce
child support obligation (13 Del. C. §2216) and for other lawful purposes.
Revised 10/2018
APPLICATION FOR LICENSED ASSOCIATE COUNSELOR OF MENTAL HEALTH
IDENTIFYING AND CONTACT INFORMATION
1. Full Name: __________________________________ ________________________________ _________________
Last First Middle
2. Other Names Used: _______________________ ________________________ ______________________ None
(Include maiden, prior married, alternate spellings)
3. Date of Birth (month/day/year): ______________ Gender: Male Female
4. Have you been issued a U.S. Social Security Number? Yes No If yes, enter your SSN: __________________
If no, you must file a Request for Exemption from Social Security Number Requirement.
5. Mailing Address: _______________________________________________________________________________
________________________________________________ _______________________________ _____________
City State Zip
6. Phone: _______________ ________________ Email: ________________________________________ None
Home Work
EXAMINATION HISTORY
You must have passed the NCE or NCMHCE exam or other examination acceptable to the Board.
7. Enter the following information about your national examination:
✓
EXAMINATION NAME DATE OF EXAM
NCE
NCMHCE
Other:___________________________________________
Arrange for the organization to send verification of your scores directly to the Board office.
GRADUATE EDUCATION
8. Enter this information about the program from which you received your highest degree.
Highest Degree Received: _________________________________________ Degree Date: ___________________
School Name: __________________________________________________________________________________
Address: __________________________________________ _______________________ ________ ___________
Street City State Zip
If applying by examination, arrange for the school to send an official transcript directly to the Board office.
9. Do you have a Master's degree in clinical mental health counseling with at least 60 graduate semester hours or an
equivalent degree in clinical mental health counseling? Yes
No If no, submit
• completed the Evaluation of Coursework form
• course catalog or course descriptions.
CANNON BUILDING
861
SILVER LAKE BLVD., SUITE 203
DOVER, DELAWARE 19904-2467
STATE OF DELAWARE
BOARD OF MENTAL HEALTH AND CHEMICAL
DEPENDENCY PROFESSIONALS
TELEPHONE
:
(302)
744-4500
FAX: (302) 739-2711
WEBSITE: DPR.DELAWARE.GOV
EMAIL: customerservice.dpr@state.de.us
Revised 10/2018
LICENSURE HISTORY
10. Have you ever held a license to practice as a mental health professional in any jurisdiction other than Delaware?
Yes No If yes, enter the following information about each mental health license that you have ever held.
JURISDICTION
TYPE OF LICENSE
HELD
LICENSE
NUMBER
LICENSURE DATES
From
To
Arrange for the Board office to receive a verification of licensure from each jurisdiction where you have ever
held a mental health professional license.
PLANS FOR DIRECT SUPERVISION AND PROFESSIONAL COUNSELING EXPERIENCE
Typically, the Board will only accept a LPCMH licensed in any jurisdiction (state, U.S. Territory or District of
Columbia). The Board may accept another licensed mental health professional only if there is a compelling
clinical reason to use an alternative supervisor.
11. Is your clinical supervisor a Delaware-licensed Professional Counselor of Mental Health? Yes No
If no, explain in detail (1) the steps you took to secure a Delaware-licensed LPCMH to supervise you
and (2) why you are proposing another professional as your supervisor.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
• Arrange for your clinical supervisor to complete and sign the form entitled
PLANNED DIRECT
SUPERVISION to verify the hours of direct supervision that you will receive. If you will receive direct
supervision in more than one period under different supervisors, have the approved clinical supervisor for
each period complete a form for the period during which he or she will supervise you.
• Arrange for an administrative supervisor to complete the form entitled PLANNED PROFESSIONAL COUNSELING
EXPERIENCE to verify the hours of post-Master’s professional clinical counseling experience that you will receive
while not under the direct supervision of an approved clinical supervisor. If you will have more than one period of
experience, arrange for a separate box to be completed for each period of experience.
DISCLOSURES
12. Has any jurisdiction ever denied your application for licensure? Yes No If yes, enclose a detailed explanation
and all relevant documentation.
13. Have you received any administrative penalties regarding your practice of professional mental health counseling in
any jurisdiction (state, U.S. Territory or District of Columbia), including but not limited to the following:
Fines? Yes No
Formal reprimands? Yes No
License suspensions? Yes No
License revocations (except for non-payment of fees)? Yes No
Probationary limitations? Yes No
Other? Yes No If yes, what kind of penalty: _______________________________________________
If yes to any item, enclose a detailed explanation and all relevant documents.
Revised 10/2018
14. Are any disciplinary actions pending against you? Yes No If yes, enclose a detailed explanation of any
pending actions and all relevant documentation.
15. Have you done any of the following grounds for discipline:
• committed or knowingly cooperated in a fraud or material deception in order to acquire a license? Yes No
• impersonated another person holding a license? Yes No
• allowed another person to use your license? Yes No
• aided or abetted an unlicensed person to represent himself or herself as a licensee? Yes No
If yes to any, enclose a detailed explanation of the violations and all relevant documentation.
16. Do you currently excessively use or abuse drugs or have you done so in the past three years? Yes No If yes,
enclose a detailed explanation and all relevant documentation.
17. Have you engaged in an act which involved consumer fraud or deception, restraint of competition, or price fixing?
Yes No If yes, enclose a detailed explanation and all relevant documentation.
18. Do you have any impairment related to drugs or alcohol or a finding of mental incompetence by a physician that would
limit your ability to act as a professional counselor of mental health or associate counselor of mental health in a
manner consistent with the safety of the public? Yes
No If yes, enclose a detailed explanation and all
relevant documentation.
19. Have you been penalized for any willful violation of the code of ethics adopted by the Board, the NBCC code of ethics
or other similar professional mental health counseling standard? Yes
No If yes, enclose a detailed
explanation and all relevant documentation.
20. Are you presently in violation of any Rule and Regulation set forth by the Delaware Board of Mental Health and
Chemical Dependency Professionals? Yes
No If yes, enclose a detailed explanation of all such violations
and all relevant documentation.
Complete the Criminal History Record Check Authorization form to request State of Delaware and Federal Bureau
of Investigations criminal background checks. Follow the instructions on the authorization form to arrange to be
fingerprinted.
DUTY TO REPORT
21. To obtain a license in Delaware, you must certify that you understand that you have a mandatory duty to report, in
writing, within 30 days of becoming aware of information that you reasonably believe indicates that any healthcare
provider including (but not limited to) any practitioner certified and registered to practice medicine in Delaware or
licensed by the Board of Mental Health and Chemical Dependency Professionals
• has engaged, or is engaging, in conduct that would constitute grounds of discipline under their licensing laws, or
• may be unable to practice with reasonable skill and safety to the public by reason of mental illness or mental
incompetence, physical illness (including deterioration through the aging process or loss of motor skill), or
excessive abuse of drugs (including alcohol).
I certify that I have read and understand 24 Del. C. §3018, 24 Del. C. §1730, 24 Del. C. §1731 and 24 Del. C. §1731A
and that I understand my duty to report to the Division of Professional Regulation. Yes No
22. To obtain a Delaware license, you must certify that you understand that you have a mandatory obligation to make an
immediate oral report to the Department of Services for Children, Youth and Their Families if you know of, or you
suspect, child abuse or neglect under Chapter 9 of Title 16 and to follow up with any requested written reports.
I certify that I have read and understand 16 Del. C. §903
and that I understand my duty to report. Yes No
23. To obtain a Delaware license, you must certify that you understand that you have a mandatory duty to self report
when your license to practice in another jurisdiction has been disciplined, surrendered, suspended or revoked.
I certify that I have read and understand 24 Del. C. §3009 (a)(7)
and that I understand my duty to self report.
Yes No
Continued on next page
Revised 10/2018
To ensure consideration of your license application at the next Board meeting, the Board office must receive
all of these items no later than 4:30 PM ten full working days before the Board’s meeting date:
• Completed, signed and notarized application form
• Fee payment
• All required supporting documentation.
Applications that are not complete within 12 months of filing may be considered abandoned and discarded.
When your application is complete, allow 4-8 weeks to receive your license.
AFFIDAVIT
The undersigned applicant for Licensed Associate Counselor of Mental Health, being sworn, deposes and affirms that he
or she is the person who executed this application; that the statements contained on this application are true in every
respect; that he or she has not suppressed or withheld information that might affect this application; that he or she will
abide by the laws and the ethical standards of this profession; and that he or she has read and understands this
statement.
The applicant further affirms that he or she has read and understands the PLANNED DIRECT SUPERVISION and
PLANNED PROFESSIONAL COUNSELING EXPERIENCE forms in the application and that he or she will promptly
report any change in the plan to the Board office.
The applicant authorizes all jurisdictions to release any and all information regarding his/her disciplinary history and
current status to the Delaware Board of Mental Health and Chemical Dependency Professionals.
Signature of Applicant: ___________________________________________________ Date: __________________
State of _____________________________ County of ________________________
Sworn to before me and subscribed in my presence this ______________ day of ___________________2______.
Signature of Notary: __________________________________________
SEAL
My commission expires: ____________________
APPLICATIONS THAT ARE UNSIGNED, NOT NOTARIZED, INCOMPLETE OR NOT ACCOMPANIED BY THE
REQUIRED FEE WILL BE REJECTED.
Revised 10/2018
PLANNED DIRECT SUPERVISION
INSTRUCTIONS
The proposed clinical supervisor completes this PLANNED DIRECT SUPERVISION form to document hours that he or she will be
directly supervising an LACMH. The following supervision information applies:
• Professional direct supervision is face-to-face consultation, on a regularly scheduled basis, between a supervisee and a Licensed
Professional Counselor of Mental Health (LPCMH) or other behavioral health professional approved by the Board. The services rendered
must be consistent with the supervisee's education, training and experience.
• The applicant must complete a total of at least 1,600 hours of post-Masters direct mental health counseling experience while under the
direct supervision of one or more approved clinical supervisors.
o At least 1,500 of the 1600 hours must be actual face-to-face direct mental health counseling services. Of the 1,500 hours, at least 750
hours must be individual face-to-face client sessions and must include actually providing direct mental health counseling services. The
other 750 hours may be individual, group, couple or family counseling services or some combination of those services.
o At least 100 hours must be face-to-face professional direct supervision with your supervisor. Face to face supervision includes both in
person and live video conferencing. Live video conferencing must not exceed 50 percent of the total 100 hours of supervision.
o Individual Direct Supervision must be one to one, face to face meetings between the you and your supervisor. The entire 100 hour
requirement may be fulfilled by individual supervision.
o Group Supervision must be face to face meetings between the supervisor and no more than six supervisees. No more than 40
hours of group supervision shall be acceptable towards fulfillment of the 100 hour direct supervision requirement.
• If the proposed supervisor is not licensed in Delaware, submit a verification of licensure history for the supervisor showing at least
five years of post-licensure.
The LACMH must complete all of the required hours in a period of not less than two but no more than four consecutive years.
Applicant Name: ________________________________________ _______________________ _______________
Last First Middle
INFORMATION ABOUT CLINICAL SUPERVISOR - To be completed by Clinical Supervisor only
1. Supervisor Name: _____________________________________ _______________________ ____________________
Last First Middle
2. Supervisor’s Practice Name (if applicable): ___________________________________________________________________
3. Practice Address: _______________________________________________________________________________________
________________________________________________________ ______________________________ _______________
City State Zip
4. Phone: ____________________ Email: ________________________________________
5. Are you a Delaware-licensed LPCMH? Yes No If yes, enter your license number: PC - __________________
If no, SKIP to Question 9. If yes, continue to Question 6.
6. Have you practiced for two years post-licensure in any jurisdiction? Yes No
7. Are any disciplinary proceedings or unresolved complaints pending against your license? Yes No
8. Is your license currently in good standing? Yes No SKIP to the DIRECT SUPERVISION HOURS section.
9. If your answer to Question 5 is NO, enter the following information about your professional licensure and complete Question 10:
✓
LICENSE(S) HELD (check all that apply)
JURISDICTION
LICENSE #
ISSUE DATE
Professional Counselor of Mental Health
Clinical Social Worker
Marriage and Family Therapist
Psychologist
Psychiatrist
Advanced Practice Registered Nurse
CANNON BUILDING
861
SILVER LAKE BLVD., SUITE 203
D
OVER, DELAWARE 19904-2467
STATE OF DELAWARE
BOARD OF MENTAL HEALTH AND CHEMICAL
DEPENDENCY PROFESSIONALS
TELEPHONE:
(302)
744-4500
FAX: (302) 739-2711
WEBSITE: DPR.DELAWARE.GOV
EMAIL: customerservice.dpr@state.de.us
Revised 10/2018
10. I certify that :
I have at least five years of post-licensure experience in good standing. Submit official verification of your license
from that jurisdiction.
I have read and understand with the requirements for licensure in Delaware.
I have read and understand the statutes, rules and regulations of the Delaware Board of Professional Counselors of
Mental Health and Chemical Dependency Professionals, 24 Del. C. §3001-3064
.
DIRECT SUPERVISION HOURS
11. Enter the dates of planned post-Master’s clinical experience that the applicant will provide under
your direct supervision: From ______________ To _______________
Month/Year Month/Year
12. During the period entered above, how many total hours of face-to-face professional direct supervision will you provide to the
applicant? ____________ Of this total, enter the breakout:
Individual supervision hours: ___________ Group supervision hours: _____________
13. During this period, how many hours of individual face-to-face direct client contact will the applicant provide under your direct
supervision? ________________ (At least 750 of the 1,500 hours of direct mental health counseling experience must be
individual face-to-face client sessions.)
14. During this period, how many hours of group, couple, or family face-to-face direct client contact will the applicant provide under
your direct supervision? __________ (Must not exceed 750 hours)
15. Describe the clinical activities in which the applicant will participate. (Examples include clinical assessments, crisis interventions,
and individual/group counseling.) ___________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
16. I attest that I have discussed the following with the applicant before completing this form. Answer each question. If you answer
‘NO’ or ‘N/A’ to any question, enclose a written statement explaining why.
I have explained to the applicant that I have the training, credentials, and competence to provide supervision in
Delaware.
Yes No N/A
I have discussed my role and responsibilities with the applicant. These include:
• Evaluating the applicant’s clinical competence and preparedness to practice independently
• Ensuring that the applicant practices within the professional and ethical standards of the field
• Ensuring that the applicant is aware of the rules and regulations for practicing independently in Delaware
Yes No N/A
Yes No N/A
Yes No N/A
I have discussed a contingency plan for dealing with emergencies and crises. Yes No N/A
I have explained my model and style of supervision to the applicant. Yes No N/A
I have reviewed the supervisory feedback process, including performance appraisal, evaluation feedback,
documentation, and feedback intervals.
Yes No N/A
I have explained how I will assess the applicant’s comprehension of ethical, legal, and professional
requirements.
Yes No N/A
I have ensured that the appropriate liability coverage is in place for the applicant and for myself. Yes No N/A
I have developed a process to address any issues or concerns regarding the applicant’s performance,
including the utilization of a third-party to remediate any performance issues, consultation for additional
assistance, or options to address concerns.
Yes No N/A
I have explained my role in endorsing the applicant for licensure or employment based on the applicant’s
demonstrated competence and qualifications and that I will not endorse an applicant whom I believe to be
impaired in any way that would interfere with the performance of the duties associated with the endorsement.
Yes No N/A
I have explained to the applicant that I have the training, credentials, and competence to provide supervision to
a LACMH/LAMFT pursuant to the regulations of Delaware Board of Mental Health and Chemical Dependency
Professionals.
Yes No N/A
I have the ethical and legal authority to access confidential client information of the supervisee. Note: For
supervisors who are not employees of the clinical setting where the supervisee is seeing clients a written
agreement between the supervisor and agency should be executed.
Yes No N/A
I certify that I have personally completed this information and that the information provided herein is accurate and complete
to the best of my knowledge.
Clinical Supervisor Signature: ______________________________________________ Date: _______________
This period must
not span more than
four years.
Revised 10/2018
PLANNED PROFESSIONAL COUNSELING EXPERIENCE
INSTRUCTIONS
An administrative supervisor completes the PLANNED PROFESSIONAL COUNSELING EXPERIENCE form to document
estimated additional hours of professional counseling experience that the applicant will accrue while not under the direct
supervision of an approved clinical supervisor.
Remember that these additional experience hours, when added to the 1,600 or more hours of direct supervision
verified by the approved clinical supervisor(s), must total at least 3,200 hours. The LACMH must complete all of
the required hours in a period of not less than two but no more than four consecutive years.
Applicant Name: ______________________________________ _______________________ _______________
Last First Middle
INFORMATION ABOUT PERSON VERIFYING EXPERIENCE – To be completed by Administrative Supervisor only
1. Name: __________________________________________ ________________________ _________________
Last First Middle
2. Practice Name Where Experience Will Occur: ______________________________________________________
3. Describe Practice: ____________________________________________________________________________
___________________________________________________________________________________________
Examples include group practice, community mental health agency.
4. Practice Address: ____________________________________________________________________________
____________________________________________ ______________________________ ________________
City State Zip
5. Phone: ____________________ Email: ________________________________________None
EXPERIENCE HOURS
6.
Enter the period when you will supervise the LACMH: From ____________ To ___________
Month/Year Month/Year
7. Calculate and enter the total number of hours of professional counseling experience
that the applicant will engage in during this period while not under direct supervision of
an approved clinical supervisor: _______________
CERTIFICATION
I certify that I have personally completed this information and that the information provided herein is accurate
and complete to the best of my knowledge.
Administrative Supervisor Signature: ______________________________________________ Date: ___________
Answers such as “40
hours/week” will not be
accepted.
CANNON BUILDING
861
SILVER LAKE BLVD., SUITE 203
D
OVER, DELAWARE 19904-2467
STATE OF DELAWARE
BOARD OF MENTAL HEALTH AND CHEMICAL
DEPENDENCY PROFESSIONALS
TELEPHONE:
(302)
744-4500
FAX: (302) 739-2711
WEBSITE: DPR.DELAWARE.GOV
EMAIL: customerservice.dpr@state.de.us
This period must
not span more than
four years.
Revised 10/2018
EVALUATION OF COURSEWORK
INSTRUCTIONS
Complete and submit this form if you do not have a Master's degree in clinical mental health counseling with at least 60 graduate
semester hours or an equivalent degree in clinical mental health counseling. This applies when
• your graduate program of studies is not from a regionally accredited institution of higher education, or
• your degree is not in clinical mental health counseling but in a related discipline.
The degree you received must encompass the following eight (8) common core areas:
PROFESSIONAL COUNSELING ORIENTATION AND
ETHICAL PRACTICE
COURSE # COURSE TITLE
History and philosophy of the counseling profession & its
specialty areas
The multiple professional roles and functions of counselors
across specialty areas
Counselor’s roles and responsibilities as members of
interdisciplinary community outreach & emergency
management response teams
The role and process of the professional counselor
advocating on behalf of the profession
Advocacy processes needed to address institutional and
social barriers
Professional counseling organizations & current issues
Professional counseling credentialing and the effects of
public policy on these issues
Current labor market information relevant to opportunities for
practice within the counseling profession
Ethical standards of professional counseling organizations
and applications of ethical and legal considerations
Technology’s impact on the counseling profession
Strategies for personal and professional self-evaluation and
implications for practice
Self-care strategies appropriate to the counselor role
The role of counseling supervision in the profession
SOCIAL AND CULTURAL DIVERSITY COURSE # COURSE TITLE
Diverse groups multicultural and pluralistic characteristics
Theories and models of multicultural counseling, cultural
identity development and social justice and advocacy
Multicultural counseling competencies
The impact of heritage, attitudes, beliefs, understandings,
and acculturative experiences on views of others
The effects of power & privilege for counselors & clients
Help-seeking behaviors of diverse clients
The impact of spiritual beliefs on clients’ and counselors’
worldviews
Strategies for identifying and eliminating barriers, prejudices,
& oppression and discrimination
C
ANNON BUILDING
861
SILVER LAKE BLVD., SUITE 203
DOVER, DELAWARE 19904-2467
STATE OF DELAWARE
BOARD OF MENTAL HEALTH AND CHEMICAL
DEPENDENCY PROFESSIONALS
TELEPHONE:
(302)
744-4500
FAX: (302) 739-2711
WEBSITE: DPR.DELAWARE.GOV
EMAIL: customerservice.dpr@state.de.us
Revised 10/2018
HUMAN GROWTH AND DEVELOPMENT COURSE # COURSE TITLE
Theories of individual and family development across the
lifespan
Theories of learning
Theories of normal & abnormal personality development
Theories & etiology of addictions & addictive behaviors
Biological, neurological and physiological factors that affect
human development, functioning, and behavior
Systemic and environmental factors that affect human
development, functioning, and behavior
Effects of crisis, disasters, and trauma on diverse individuals
across the lifespan
A general framework for understanding differing abilities and
strategies for differentiated interventions
Ethical and culturally relevant strategies for promoting
resilience and optimum development and wellness across
the lifespan
CAREER DEVELOPMENT COURSE # COURSE TITLE
Theories and models of career development, counseling,
and decision making
Approaches for conceptualizing the interrelationships among
and between work, mental well-being, relationships, and
other life roles and factors
Processes for identifying and using career, vocational,
educational, occupational and labor market information
resources, technology, and information systems
Approaches for assessing the conditions of the work
environment on clients’ life experiences
Strategies for assessing abilities, interests, values,
personality and other factors that contribute to career
development
Strategies for career development program planning,
organization, implementation, administration, and evaluation
Strategies for advocating for diverse clients’ career and
educational development and employment opportunities in a
global economy
Strategies for facilitating client skill development for career,
educational, and life-work planning and management
Methods of identifying and using assessment tools and
techniques relevant to career planning and decision making
Ethical and culturally relevant strategies for addressing
career development
COUNSELING AND HELPING RELATIONSHIPS COURSE # COURSE TITLE
Theories and models of counseling
A systems approach to conceptualizing clients
Theories, models & strategies for understanding & practicing
consultation
Ethical & culturally relevant strategies for in-person &
technology-assisted relationships
The impact of technology on the counseling process
Counselor characteristics & behaviors influencing
counseling process
Essential interviewing, counseling & case conceptualization
skills
Developmentally relevant counseling treatment or
intervention plans
Development of measurable outcomes for goals
Theories and models of counseling
Revised 10/2018
GROUP COUNSELING AND GROUP WORK COURSE # COURSE TITLE
Evidence-based counseling strategies and techniques for
prevention and intervention
Strategies to promote client understanding of and access to
a variety of community-based resources
Suicide prevention models and strategies
Crisis intervention, trauma-informed, and community-based
strategies, such as Psychological First Aid
Processes for aiding students in developing a personal
model of counseling
Theoretical foundations of group counseling and group work
Dynamics associated with group process and development
Therapeutic factors and how they contribute to group
effectiveness
Characteristics and functions of effective group leaders
Approaches to group formation, including recruiting,
screening, and selecting members
Types of groups and other considerations that affect
conducting groups in varied settings
Ethical and culturally relevant strategies for designing and
facilitating groups
Direct experiences in which students participate as group
members in a small group activity (min of 10 clock hours)
ASSESSMENT AND TESTING COURSE # COURSE TITLE
Historical perspectives concerning the nature and meaning
of assessment and testing in counseling
Methods of effectively preparing for and conducting initial
assessment meetings
Procedures for assessing risk of aggression or danger to
others, self-inflicted harm, or suicide
Procedures for identifying trauma and abuse and for
reporting abuse
Use of assessments for diagnostic and intervention planning
purposes
Basic concepts of standardized and non-standardized
testing, norm-referenced and criterion-referenced
assessments, and group and individual assessments
Statistical concepts, including scales of measurement,
measures of central tendency, indices of variability, shapes
and types of distributions, and correlations
Reliability and validity in the use of assessments
Use of assessments relevant to academic/educational,
career, personal, and social development
Use of environmental assessments and systematic
behavioral observations
Use of symptom checklists, and personality and
psychological testing
Use of assessment results to diagnose developmental,
behavioral, and mental disorders
Ethical & and culturally relevant strategies for selecting,
administering, and interpreting assessment and test results
RESEARCH AND PROGRAM EVALUATION COURSE # COURSE TITLE
The importance of research in advancing the counseling
profession, including how to critique research to inform
counseling practice
Identification of evidence-based counseling practices s
Needs assessment
Development of outcome measures for counseling programs
Evaluation of counseling interventions and programs
Revised 10/2018
RESEARCH AND PROGRAM EVALUATION, continued COURSE # COURSE TITLE
Qualitative, quantitative, and mixed research methods
Designs used in research and program evaluation
Statistical methods used in conducting research and
program evaluation
Analysis and use of data in counseling
Ethical and culturally relevant strategies for conducting,
interpreting, and reporting the results of research and/or
program evaluation
Submit a course catalog or course descriptions in addition to this form.
Revised 10/2018
Instructions for Requesting a Criminal Background Check
Both State of Delaware and Federal Bureau of Investigation criminal background checks are required.
Applicant Notification
Your fingerprints will be used to check the criminal history records of the Federal Bureau of Investigation (FBI). You have
the opportunity to challenge the accuracy of the information contained in the FBI identification record. See
Title 28, CFR
16.34 for the procedure to obtain a change, correction or update in the FBI record.
Locations
Kent County – Primary Facility
State Bureau of Identification
Blue Hen Mall & Corporate Center
655 S. Bay Rd. Suite 1B
Dover, DE 19901
Walk-ins accepted: Mon 8:30 am – 6:30 pm, Tue - Fri 8:30 am – 3:30 pm
Customer Service: (302) 739-2134
New Castle County - Satellite Facility
State Police Troop Two
100 LaGrange Ave
Newark, DE 19702
(between Rts. 72 and 896 on Rt. 40)
By appointment only
Scheduling: (302) 739-2528 (local)
(800) 464-4357 (toll free)
Sussex County – Satellite Facility
Thurman Adams State Service Center
546 S. Bedford Street, Rm. 202
Georgetown DE 19947
(across from DelDOT & Troop 4)
By appointment only
Scheduling: (302) 739-2528 (local)
(800) 464-4357 (toll free)
Applicants in Delaware
1. If you are using the New Castle County or Sussex County locations, call (800) 464-HELP (4357) to schedule an
appointment. No appointments are needed at the Kent County location.
2. Take the completed Authorization for Release of Information form to one of the offices listed above with the fee of
$65.00, to cover both the State of Delaware and Federal Bureau of Investigation criminal checks. Money orders
and credit cards other than American Express are accepted at all locations. New Castle and Kent Counties accept
cash; Sussex County does not accept cash. Personal checks are not accepted in any county. As fees are
subject to change, contact the agency where you plan to submit your forms for current fees.
Applicants Not in Delaware (including Out-of-State or Outside the United States)
1. Your local police agency can fingerprint you. All types of fingerprint cards are accepted. Or, you may print a FD-
258 fingerprint form available on the FBI website at www.fbi.gov – click Services, then Identity History Summary
Checks, then scroll down to Option 1, Step 2, and click the link for standard fingerprint form (FD-258). You may
print the form on regular paper.
2. Your Authorization for Release of Information form and the fingerprint card must be complete. If identifying
information is missing (such as name, date of birth, race, gender, etc.), your form will be returned.
3. Mail the Authorization form, fingerprint card, and certified check or
money order (personal checks are not accepted) for $65.00 made
payable to “Delaware State Police” to:
DO NOT SEND THIS FORM OR FEE TO YOUR PROFESSION’S BOARD OFFICE.
DO NOT SEND THIS FORM OR FEE TO THE DIVISION OF PROFESSIONAL REGULATION.
ALLOW FOUR WEEKS FOR RECEIPT OF RESULTS.
Delaware State Police
State Bureau of Identification (SBI)
PO Box 430
Dover, DE 19903-0430
Revised 10/2018
AUTHORIZATION FOR RELEASE OF INFORMATION
CRIMINAL HISTORY RECORD CHECK FOR PROFESSIONAL LICENSURE APPLICANTS
Please print or type all information in black ink.
Check the type of license for which you are applying:
Adult Entertainment
Mental Health (LPCMH, LCDP, LMFT, LACMH, LAMFT,
LPAT, LAAT)
Physical Therapy/Athletic Trainer
Charitable Gaming Vendor Nursing (RN, LPN, APRN) Podiatry
Chiropractic Nursing Home Administrator Psychology
Dental Occupational Therapy
Real Estate Appraiser (includes
Appraisal Management Company)
Funeral Optometry Speech/Hearing
Massage
Pharmacy (includes key personnel of facilities licensed by
Board of Pharmacy)
Social Work
Medical
(Physicians (MD, DO and Administrative Medical), Physician Assistants, Respiratory Care
Practitioners, Eastern Medicine Practitioners, Acupuncture Practitioners, Genetic Counselors,
Polysomnographers, Midwifery Practitioners (CM, CPM))
Texas Hold’em Individual
Print your current full name:
____________________________________ ____________________________________ ________________ _______________
Last Name First Name Middle Initial Suffix (e.g., Jr., Sr.)
Enter all other names you have used in the past (including, but not limited to, maiden name, former married
names, alternative spellings):
1. __________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________
4. __________________________________________________________________________________
As an applicant, I authorize release of any and all information that you have concerning my CRIMINAL HISTORY
RECORD INFORMATION. I hereby release you, your organization, the State of Delaware and others from any liability or
damage which may result from furnishing this information:
SIGNATURE OF PERSON PRINTED: __________________________________________ Date: _________________
Phone: Home _______________________ Work _______________________
Mail the results of my criminal history request to: Division of Professional Regulation
861 Silver Lake Boulevard, Suite 203
Dover DE 19904
SLC D420A
USE OF CRIMINAL HISTORY RECORD INFORMATION IS RESTRICTED BY LAW AND SHALL BE LIMITED TO THE
PURPOSE FOR WHICH IT WAS GIVEN. MISUSE CONSTITUTES A CRIMINAL VIOLATION.
CANNON BUILDING
861 SILVER LAKE BLVD., SUITE 203
D
OVER, DELAWARE 19904-2467
STATE OF DELAWARE
TELEPHONE:
(302)
744-4500
FAX: (302) 739-2711
WEBSITE: DPR.DELAWARE.GOV
EMAIL: customerservice.dpr@state.de.us
Revised 10/2018
Revised 10/2018
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Form 861: APPLICATION FOR LICENSED ASSOCIATE COUNSELOR OF (Department of Technology and Information)

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Completed 20 November 2020

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