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Provisional Mental Health Practitioner and Provisional Master Social Worker

PLMHP: You will need a license as a provisional mental health practitioner in order to earn 3,000 hours of supervised post-masters

experience in mental health practice in Nebraska (to obtain a full license as a MHP or LIMHP) and to provide treatment, assessment,

psychotherapy, counseling, or equivalent activities to individuals, couples, families, or groups for behavioral, cognitive, social, mental,

or emotional disorders, including interpersonal or personal situations. https://www.nebraska.gov/rules-and-

regs/regsearch/Rules/Health_and_Human_Services_System/Title-172/Chapter-094.pdf

To obtain the PLMHP, you must:

1. Have a masters/doctorate degree of which the course work and training leading to the degree was primarily therapeutic

mental health in content (see section 007 of regulations) and included a practicum/internship (see section 002 of regulations). A

practicum/internship completed after September 1, 1995 must include a minimum of 300 clock hours of direct client contact under

supervision.

2. Be at least 19 years old and of good character.

LMHP Supervision: If you will be seeking licensure as a LMHP, the following applies. You are NOT required to register your PLMHP

supervisor with our office, but you must meet the following to obtain the LMHP:

1. Be supervised by a Nebraska licensed mental health practitioner or independent mental health practitioner or psychologist or

qualified physician when providing mental health services

AND,

2. You must obtain at least 3,000 hours of MHP experience that includes a minimum of 1,500 direct (face-to-face) client contact hours

AND,

3. You must meet face-to-face with your supervisor for at least 1 hour per week.

LIMHP Supervision: If you will be seeking licensure as a LIMHP, refer to section 38-2124 of the statutes for the hours and

supervision requirements at: https://dhhs.ne.gov/licensure/Documents/MentalHealthPracticeAct.pdf

PCMSW: If you WISH to call yourself a social worker (masters/doctorate), a certification as a provisional master social worker is

required in order to obtain 3,000 hours of social work experience (to obtain a full certificate as a MSW). Supervision: You must be

supervised by a Nebraska CMSW.

To obtain the PCMSW, you must:

1. Have a masters or doctorate degree from an approved social work program.

2. Be at least 19 years old and of good character.

Certificates: Nebraska offers additional certificates in social work, professional counseling and marriage and family therapy. You

must hold an LIMHP or LMHP in Nebraska to add a certification. The term ‘social worker (CMSW)’ ‘certified professional

counselor (CPC)’ and ‘certified marriage and family therapist (CMFT)’ is title protected, which means, if you WISH TO USE ANY OF

THESE TITLES, you must also obtain the applicable certification(s).

See exception for CMSW: (NOT requesting a MHP or Independent MHP License). You cannot provide mental health therapy; you

may ONLY provide social work activities. A description of Social work activities can be found at: https://www.nebraska.gov/rules-and-

regs/regsearch/Rules/Health_and_Human_Services_System/Title-172/Chapter-094.pdf

License Fee Waiver: If you meet one of the following waiver options, your initial license fee is waived:

1. Young Worker: You are between the ages of 19 and 25 (under the age of 26).

2. Low-Income Individual: You are enrolled in a state or federal public assistance program such as the medical assistance

program established pursuant to the Medical Assistance Act, the federal Supplemental Nutrition Assistance Program (SNAP), or

the federal Temporary Assistance for Needy Families (TANF) program, OR your household adjusted gross income is below 130%

of the federal income poverty guideline.

• If you live in Nebraska and are enrolled in a state or federal public assistance program, no further documentation is required to

be submitted.

• If you live in a state other than Nebraska and are enrolled in a state or federal public assistance program, submit a copy of a

document showing current enrollment.

• If your household adjusted gross income is at 130% of the Federal Income Poverty Guideline or below, click this link to see

the current income guidelines https://dhhs.ne.gov/licensure/Documents/LowIncomeFeeWaiverTable.pdf . To be eligible for

this waiver, you must submit a copy of your most recent tax return.

3. Military Family: You are an active duty service member in the armed services of the United States, a military spouse, honorably

discharged veteran of the armed services of the United States, spouse of such honorably discharged veteran, and un-remarried

surviving spouses of deceased service members of the armed services of the United States. To be eligible for this waiver, you must

submit a copy of your ID card, discharge paperwork, or similar document that shows you are a military family member as described

above.

MILITARY: To view licensing services available to members of the military and their spouses, visit our website at

https://dhhs.ne.gov/licensure/Pages/Professions-and-Occupations.aspx

______________________________________________________________________________________PLMHP/PCMSW Information

Checklist of Required Information: Use the following checklist to help organize your application.

NON-ENGLISH DOCUMENTS: Documents written in a language other than English must include a complete English translation. The

translation must be an original document with the translator’s notarized signature. You cannot translate your own documents.

1.  US Citizenship/Lawful Presence (and must be at least 19 years old):

(A Driver’s License is NOT acceptable)

• US Citizenship

• Birth Certificate (Hospital issued keepsake birth certificates is not acceptable)

• U.S. Passport (unexpired or expired)

• Certificate of Naturalization

• Other documents that show U.S. Citizenship

• NOT a U.S. Citizen

• I-551: Permanent Resident Card (Green Card)

• Form I-94 (Arrival-Departure Record)

• Form I-94 (Arrival-Departure Record) and Unexpired Foreign Passport

• I-766: Employment Authorization Card

• Machine Readable Immigrant Visa

• I-20: Certificate of Eligibility for Nonimmigrant (F-1) Student Status

• DS2019: Certificate of Eligibility for Exchange Visitor (J-1) Status

• Temporary I-551 Stamp on Passport or I-94

• I-327: Reentry Permit

• I-571: Refugee Travel Document

• Other

NOTE: Documents (other than those for U.S. Citizenship) are verified by our office through the Department of Homeland Security.

This process may take up to 30 days.

2.  Fee: $125 (unless you qualify for a fee waiver). Pay by check or money order (payment is processed upon receipt). We

are unable to accept electronic payments. Fee payable to: Licensure Unit.

3.  Education:

 Transcript: An official transcript verifying receipt of your masters or doctorate degree, which the degree focus is

primarily therapeutic mental health. This transcript may be submitted with your application in a sealed envelope, directly by your

school/college via paper, or by an electronic transcript service to

dhhs.licensure2117@nebraska.gov

 Coursework: If you received a master’s/doctoral degree from a program other than those listed below, you must

submit a syllabus for each course listed on the application and it must be from the time you completed course.

• Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE)

• Council for Accreditation of Counseling and Related Educational Programs (CACREP)

• Council on Social work Education (CSWE)

• Council on Rehabilitation Education (CORE)

• The American Psychological Association (APA) for a doctoral degree program enrolled in by a person who has a masters

degree or its equivalent in psychology

If you do not know whether your program was accredited, go to the applicable accreditation web site before completing

your application.

 Practicum/Internship: You must submit the affidavit of practicum/internship (found on page 5). This practicum or

internship must have been completed as part of your degree program (not as work experience after your degree was

issued.

Information Relating to Military Education, Training, or Service: If you have completed education, training, or service

that you believe is substantially similar to the education required for this credential while you were a member of the military, you may

submit such evidence with your application for review.

______________________________________________________________________________________PLMHP/PCMSW Information

4.  Conviction Information: If you have EVER received a ticket from law enforcement or animal control, check the court system

to see if the ticket is on your record as a misdemeanor or felony conviction. Speeding tickets are not misdemeanors or felonies. You

are required to list ALL convictions (regardless of when they occurred) on the application; you are NOT required to list infractions,

diversions or dismissals. Misdemeanor and felony convictions can either be processed through traffic or criminal court, so when you

check with the county court/district court, you should ask for both traffic and criminal court misdemeanor/felony convictions.

If you have convictions, you must submit:

(i) A copy of the court record related to all misdemeanor and felony convictions, that includes the statement of charges and final

disposition, if the conviction(s) occurred in a state other than Nebraska;

(ii) An explanation of the events leading to the conviction (what, when, where, why) and a summary of actions that the applicant has

taken to address the behaviors or actions related to the conviction; and

(iii) A letter from the applicant’s probation officer addressing the terms and current status of the probation, if the applicant is currently

on probation.

If you had an alcohol and drug evaluation and/or completed treatment, to assist the Board and Department in review of any

drug and/or alcohol conviction(s), the treatment provider must submit all evaluations/discharge summaries directly to the

Department.

The following provides SOME examples of convictions; this is NOT a complete list

• MIP/ Tobacco Use by Minor

• DUI / DWI

• Controlled Substance

• Open Container

• Shoplifting / Theft / Burglary

• Unauthorized use of a Financial Transaction

• Disturbing the Peace

• Assault / Prostitution

• Disorderly Conduct / Disorderly House

• Reckless Driving

• Driving under Suspension / Revocation

• License Vehicle without Liability Insurance

• Fail to Appear in Court

• False Information or Reporting

• Leave the Scene of an Accident

• Operator not Carrying License

• Unlawful Display of Plates/Renewal tabs

• Park Rule Violation / Curfew Violation

• Dog at Large / Fail to Vaccinate Animal

• Littering / Fireworks / Bad Check

NOTE: If you have any criminal charges or license disciplinary actions pending that result in a conviction or license

discipline, you are required to report such action to the Investigative Unit within 30 days of the conviction or disciplinary action.

Reporting forms can be obtained at the following website:

https://dhhs.ne.gov/Pages/Investigations.aspx or by phone 402-471-

0175.

4.  Licensing Information: If you currently hold or have held a credential to provide health related services in a state/jurisdiction

other than Nebraska, you must submit verification of the license(s) even if that license is no longer current.

 Disciplinary Action: If you had any disciplinary action(s) taken against your credential, submit a copy of the discipline

Application Processing:

You can verify receipt and issuance of your application at the following web site: https://www.nebraska.gov/LISSearch/search.cgi If

your file shows ‘status: pending’, your application has been received by the Department and is in the review process.

All applications will be reviewed in date order received. Once reviewed, you will receive an e-mail or letter within approximately

10 days advising you that your license has been issued or that your application is incomplete. If incomplete, you will be informed of

how to complete your application. You have 90 days to complete your application; if not completed within this 90 days, your

application will be closed and all documents destroyed. A new application will then be required.

Records Retention Schedule: When your license is issued, your application and documents will be kept by the Department for 5

years; after 5 years all documents will be destroyed. We encourage you to keep a copy of your application for your records.

Contact Information:

Licensure Unit

301 Centennial Mall South (14

and M st)

P.O. Box 94986

Lincoln, Nebraska 68509-4986

Telephone: 402-471-2117 E-Mail: dhhs.licensure2117@nebraska.gov

2021

Licensure Unit

P.O. Box 94986

Lincoln, Nebraska 68509-4986

Telephone: 402-471-4918

FAX: 402-742-1106

-Mail: dhhs.licensure2117@nebraska.gov

PROVISIONAL APPLICATION

Licensed Mental Health Practitioner

Certified Master Social Worker

(Must be earning post-masters experience in Nebraska to qualify)

Enter your LEGAL NAME below

First Name:

Middle Name:

Last Name:

Suffix:

List any other names you are or have been known as (AKA),

including maiden and your last name on your birth certificate.).

APPLICANT DEMOGRAPHICS

Mailing Address

Country:

Zip Code:

Address Line 1:

City:

Address Line 2:

State:

Address Line 3:

County:

Is your Physical address the same? Yes □ No □

Physical Address (complete if different than Mailing Address)

Country:

Zip Code:

Address Line 1:

City:

Address Line 2:

State:

Address Line 3:

County:

Do you have a social security number?

Yes

□

Social Security Number (SSN):

Neb. Rev. Stat. §§38-123 and 38-130 requires you to provide your social security number to DHHS. Although your

number is not public information, DHHS may share your social security number for child support enforcement or other

administrative purposes and provide it to the Department of Revenue or the Department of Labor.

PLMHP / PCMSW Application – page 2

Are you a US Citizen?

Yes

□

If you are not a U.S. Citizen, list your A# or I-94#:

□

I-94 #

Date of Birth:

Place of Birth (City/State or Country):

Primary Phone Number:

□ Check box if # Outside U.S.

□

Mobile

□ Work Ext:

Secondary Phone Number:

□ Check box if # Outside U.S.

□ Mobile

□

Work Ext:

E-Mail Address:

APPLICATION FEES

Check the appropriate application(s) below:

 Provisionally Licensed Mental Health Practitioner (PLMHP)

I also plan to earn experience for a Certificate in:



Marriage and Family Therapy



Professional Counseling



Social Work

 Provisionally Certified Master Social Worker (PCMSW)

(if you check ONLY this category (PCMSW), you may NOT provide

mental health services)

FEE: $125

(unless you qualify for a fee waiver, see below)

Pay by check or money order to: Licensure Unit

Your cancelled check is your proof of payment.

Payment is processed upon receipt.

We are unable to accept electronic payments.

icenses expire 5 years from date of issuance

Fee Waivers

ICENSE FEE WAIVER: If the applicant meets one of the following options, the initial license fee is waived.

□ Young Worker: Under 26 years old.

□ Low-Income Individual:

□ Enrolled in a state or federal public assistance program, including, but not limited to, the medical assistance program

established pursuant to the Medical Assistance Act, the federal Supplemental Nutrition Assistance Program, or the federal

Temporary Assistance for Needy Families program.

State in which assistance is received: _____________________

NOTE: If you are enrolled in a state other than Nebraska, provide a copy of the state or federal documents verifying your

enrollment.

□ Household adjusted gross income is below 130% of the federal income poverty guideline, provide a copy

of your most recent tax return

□ Military Family: Active duty service member in the armed services of the United States, a military spouse, honorably discharged

veteran of the armed services of the United States, spouse of such honorably discharged veteran, and un-remarried surviving spouses

of deceased service members of the armed services of the United States.

PLMHP / PCMSW Application – page 3

CONVICTIONS

Are you currently on court-ordered probation? Yes □ No □

(If you marked yes, submit a letter from your probation officer addressing the terms and current status of your probation)

Have you EVER been convicted of a misdemeanor or felony? Yes □ No □

If yes, enter ALL misdemeanor or felony convictions (regardless of when they occurred); you are NOT required to list

infractions, diversions or dismissals. Misdemeanor and felony convictions can either be processed through traffic or

criminal court, so when you check with the county court/district court, you should ask for both traffic and criminal court

misdemeanor and felony convictions.

Name of Conviction

Date of Conviction

Name of Court Taking Action

Provide a letter of explanation for each conviction that you entered above.

If your convictions were in a state other than Nebraska, attach copies of the court documents for each conviction.

The following provides SOME examples of convictions; this is NOT a complete list

• MIP/ Tobacco Use by Minor

• DUI / DWI

• Controlled Substance

• Open Container

• Shoplifting / Theft / Burglary

• Unauthorized use of a Financial Transaction

• Disturbing the Peace

• Assault / Prostitution

• Disorderly Conduct / Disorderly House

• Reckless Driving

• Driving under Suspension / Revocation

• License Vehicle without Liability Insurance

• Fail to Appear in Court

• False Information or Reporting

• Leave the Scene of an Accident

• Operator not Carrying License

• Unlawful Display of Plates/Renewal tabs

• Park Rule Violation / Curfew Violation

• Dog at Large / Fail to Vaccinate Animal

• Littering / Fireworks / Bad Check

NOTE: If you have any criminal charges or license disciplinary actions pending that result in a conviction or license discipline,

you are required to report such action to the Investigative Unit within 30 days of the conviction or disciplinary action. Reporting

forms can be obtained at the following website

https://dhhs.ne.gov/Pages/Investigations.aspx or by phone 402-471-0175.

PLMHP / PCMSW Application – page 4

OTHER LICENSES

These questions relate to a license that you currently hold or have held, to provide health related services in a state other

than Nebraska.

ave you ever been denied the right to take a license examination in any State?

Yes □ No □

xplain:

ave you ever been denied the issuance of a license in any state?

Yes □ No □

If yes, what state(s)?

What type of license?

Explain:

Disciplinary Action: If you have had any disciplinary action(s) taken against your credential, you must submit a copy of

the disciplinary action(s), including charges and findings.

o you hold or have held licenses to provide health-related services, health services, professional services, or

environmental services in another state(s)?

Yes

□

Type of License:

State Licensed:

Type of License:

State Licensed:

Type of License:

State Licensed:

If YES, has your license ever been denied,

refused renewal, limited, suspended,

revoked or had other disciplinary measures

taken against it?

Type of Action

Date of Action

Name of State

Taking Action

Yes

□

Other Licensing Information: If you currently hold or have held a credential to provide health related services in a state or

jurisdiction other than Nebraska, you must submit verification of the license(s) even if that license is no longer current.

PLMHP / PCMSW Application – page 5

EDUCATION

YOU MUST SUBMIT an official transcript verifying receipt of your masters or doctorate degree. You may submit an

Official paper transcript or request that your school electronically submit directly the following e-mail address:

dhhs.licensure2117@nebraska.gov

We do not accept copies of transcripts sent electronically to the applicant.

Name of College/University:

Type of Degree Received:

Date of Degree:

Degree Major:

Accreditation: Check the applicable accreditation if you received a master’s or doctorate degree from one of the following:

□

Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE)

□

Council for Accreditation of Counseling and Related Educational Programs (CACREP)

□

Council on Social work Education (CSWE)

□

Council on Rehabilitation Education (CORE)

□

The American Psychological Association (APA) for a doctoral degree program enrolled in by a person who has a master’s degree

or its equivalent in psychology

PRACTICE OR USE OF A PROTECTED TITLE PRIOR TO BEING CREDENTIALED BY NEBRASKA

An individual who practices or uses a protected title in Nebraska prior to issuance of a credential is subject to assessment

of an Administrative Penalty of $10 per day up to $1,000, or other action as provided in the statutes and regulations

governing mental health practice.

If applying for a Provisional Mental Health Practitioner:

□ No. I have NOT practiced mental health in Nebraska without a credential before submitting this application?

□ Yes. I have practiced mental health in Nebraska without a credential before submitting the application?

If applying for a Provisional Master Social Worker Certificate:

□ No. I have NOT used the title Social Worker in Nebraska without a credential before submitting this application?

□ Yes. I have used the title Social Worker in Nebraska without a credential before submitting this application?

If YES to any of the questions above, what are the actual

number of days you practiced mental health or used the title

social worker, certified marriage and family therapist, or certified

professional counselor in Nebraska without a credential and

what is the business name, location and telephone number of

the practice:

Number of days:

Name of Business:

City:

Telephone #:

PLMHP / PCMSW Application – page 6

ATTESTATION

For the purpose of meeting Neb. Rev. Stat. §§4-108 through 4-114 and 38-129 (check ONE of the boxes below):

I attest that:

□ I am a citizen of the United States.

□ I am NOT a citizen of the United States. I am a qualified alien under the federal Immigration and Nationality Act, or a

non-immigrant lawfully present in the United States, with documentation such as a permanent resident card, I-94

document, asylum, etc.

□ I am NOT a citizen of the United States. I have an unexpired Employment Authorization Document (EAD) and

documentation listed under the Federal REAL ID act, such as DACA, pending asylum, pending refugee, etc.

□ I am NOT a citizen of the United States, a nonimmigrant, nor a qualified alien under the Federal

Immigration and Nationality Act.

I further attest that: I have read the application or have had the application read to me; and I am of good character and

all statements on this application are true and complete.

Print Name: _____________________________________

Signature: _____________________________________ Date: _____________________

PLMHP/PCMSW Application - Page 7

Licensur

e Unit

P. O. Box 94986 - Lincoln, NE 68509-4986

(402) 471-4905

Dhhs.licensure2117@nebraska.gov

This practicum or internship must have been completed as part of your degree program

(Work experience gained after the degree was issued, is not acceptable towards the practicum/internship)

SUPERVISOR INFORMATION:

Name of Supervisor: ___________________________________________ License Type: _______________ License #: _______

Name of Applicant: ___________________________________________

The practicum/internship was completed at: ______________________________________________________ (name of business),

in _____________________ (city) __________ (state).

SUPERVISED HOURS:

Mental health practice means the provision of treatment, assessment, psychotherapy, counseling, or equivalent activities to

individuals, couples, families, or groups for behavioral, cognitive, social, mental, or emotional disorders, including

interpersonal or personal situations.

• Direct client contact is contact between the practicum student and a client system, including collateral contacts, while providing mental

health services. Supervisory sessions involving only the practicum student and supervisor and any artificial situation where a person

presents a problem, such as role playing, is not direct client contact.

• Face to face supervision may include in-person or interactive visual imaging assisted communication which is secure and confidential.

Mental Health Practitioner:

Check this box if the applicant will be applying for a Mental Health Practitioner License.

□ I verify that the above named applicant has completed a minimum of 300 clock hours of supervised direct client contact; of these 300

hours, 150 clock hours were face-to-face in a work setting.

Independent Mental Health Practitioner:

The following applies if the applicant will be applying for an Independent Mental Health Practice license based on equivalency

of a CACREP accredited program.

□ I verify that the above named applicant has completed a minimum of at least 700 clock hours of Practicum and/or Internship as part of

his/her master’s or doctoral degree program, which included at least 280 hours of direct service with clients.

Marriage and Family Therapy:

Check this box if the applicant will also be applying for a marriage and family therapy certification.

□ I verify that the above named applicant has completed at least 300 clock hours of supervised direct client contact with individuals,

couples and families. Of these 300 hours, no more than 150 hours were with individuals.

ATTESTATION: I state that I am the person completing this form and the statements are true and complete.

I further verify that the applicant has completed a practicum/internship as part of his/her Master’s Degree Program, including the

clock hours listed above, providing mental health services under supervision.

Date (Print/Type) Name of Supervisor or Internship Director

SIGNATURE OF SUPERVISOR or INTERNSHIP DIRECTOR

MASTER’S/DOCTORATE PRACTICUM OR

INTERNSHIP VERIFICATION

The Practicum or Internship Supervisor or Director

MUST complete this form.

SECTION F: MENTAL HEALTH PRACTICE COURSEWORK

ACCREDTIED PROGRAMS: If your program is accredited by one of the following, you ARE NOT required to complete the following

coursework information.

• Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE)

• Council for Accreditation of Counseling and Related Educational Programs (CACREP)

• Council on Social work Education (CSWE)

• Council on Rehabilitation Education (CORE)

• The American Psychological Association (APA) for a doctoral degree program enrolled in by a person who has a master’s

degree or its equivalent in psychology

NON-ACCREDITED PROGRAM: If you received a masters’ or doctorate degree from a program OTHER THAN those listed as

accredited:

1. Be at least 60 graduate semester hours in duration. If the master’s degree is less than 60 semester hours, additional hours can be

attained outside of the program to equal 60 semester hours. Any additional hours must be graduate hours and have a mental health

focus to be considered as substantially equivalent

2. Consist of course work and training which was primarily therapeutic mental health in content.

3. Your degree must be from an institution of higher education approved by the Council for Higher Education Accreditation (CHEA) or

its successor.

You must submit course descriptions for each course(s) listed below from the time you completed such course; a syllabus is preferred

and must be from the time you completed each course.

An official course description must be attached for each course listed.

(LIST the name of the course, the course number and the name of the institution in which the course was completed).

PRACTICUM OR INTERNSHIP (must be part of your degree)

Course Definition: (If completed after September 1, 1995, the practicum or internship must include a minimum of 300 clock hours of

direct client contact of which 150 clock hours must be face-to-face in a work setting under the supervision of a qualified supervisor –

Any artificial situation where a person presents a problem, such as role playing, is not acceptable)

Your supervisor or internship director must submit Page 4 of this application to verify completion of the practicum/internship

requirement.

Name of Course

Course Number

College/University

If your practicum was completed prior to September 1, 1995, there is no hour requirement and Page 4 of this application is not

required to be completed or submitted; however, you must still list the practicum/internship above.

Coursework Areas Required by Nebraska

1. THEORIES AND TECHNIQUES OF HUMAN BEHAVIOR INTERVENTION: (6 semester hours or 9-quarter hours)

Course Definition: Courses that cover therapeutic techniques and strategies for human behavioral intervention. This includes major

contributions of the biological, behavioral, cognitive, and social sciences relevant to understanding assessment and treatment of the

person and his/her environment with emphases on the social systems framework, personality theories and individual development

through the life cycle, and their application.

Name of Course(s)

Course Number

College/University

2. PROFESSIONAL ETHICS AND ORIENTATION: (3 semester hours or 4.5-quarter hours)

Course Definition: The application of ethical and legal issues to the practice. Examples are: family law, codes of ethics, boundaries,

peer review, record keeping, confidentiality, informed consent, and duty to warn.

Name of Course(s)

Course Number

College/University

PLMHP/PCMSW Application - Page 8

PLMHP/PCMSW Application - Page 9

3. ASSESSMENT TECHNIQUES REQUIRED FOR MENTAL HEALTH PRACTICE: (3 semester hours or 4.5-quarter hours)

Course Definition: Includes the process of collecting pertinent data about client or client systems and their environment and

appraising the data as a basis for making decisions regarding treatment and/or referral. Examples are ability to make a clinical

diagnostic impression, knowledge of psychopathology, and assessment of substance abuse and other addictions.

Name of Course(s)

Course Number

College/University

4. HUMAN GROWTH AND DEVELOPMENT: (3 semester hours or 4.5-quarter hours)

Course Definition: The integration of the psychological, sociological and biological approaches within the life cycle. Examples are

awareness of culture, gender, or human sexuality at developmental levels, human behavior (normal and abnormal), personality theory,

and learning theory.

Name of Course(s)

Course Number

College/University

5. RESEARCH AND EVALUATION: (3 semester hours or 4.5-quarter hours)

Course Definition: Includes such areas as statistics or research design and development of research and demonstration proposals.

Name of Course(s)

Course Number

College/University

6. SOCIAL AND CULTURAL DIVERSITY (effective 7.12.2023, in addition to the above coursework, a minimum of 3 semester hours

or 4.5 quarter hours in social and cultural diversity). Required if you apply for LMHP on or after 7.12.2023

Course Description: Must focus on studies that provide an understanding of the cultural context of relationships, and issues and

trends in a multicultural and diverse society. Social and cultural diversity may include multicultural and pluralistic trends, including

characteristics and concerns between and within diverse groups nationally and internationally; attitudes, beliefs, understandings, and

acculturative experiences, including specific experiential learning activities; individual, couple, family, group, and community strategies

for working with diverse populations and ethnic groups; counselors’ roles in social justice, advocacy and conflict resolution, cultural

self-awareness, the nature of biases, prejudices, processes of intentional and unintentional oppression and discrimination, and other

culturally supported behaviors that are detrimental to the growth of the human spirit, mind, or body; theories of multicultural counseling,

theories of identity development, and multicultural competencies.

Name of Course(s)

Course Number

College/University

Undergraduate Courses:

Undergraduate courses can only be considered if the Graduate program accepted an undergraduate course(s) as meeting the above

graduate course criteria. The school must submit a notarized letter, on institutional letterhead, from an authorized person, i.e., the

Department Chair of the program, stating the undergraduate course(s) was accepted to meet the educational requirement(s) of the

master’s degree.

For Office Use Only: Date reviewed: ____________ by: _____

PLMHP/PCMSW Application – Page 10

SECTION G: MARRIAGE AND FAMILY THERAPY COURSEWORK

COMPLETE THIS COURSEWORK INFORMATION IF YOU ARE REQUESTING CERTIFICATION AS A MARRIAGE AND FAMILY THERAPIST

ACCREDITED COAMFTE PROGRAM: If you graduated from a marriage and family therapy program that COAMFTE approved you

ARE NOT required to complete the following coursework information.

NON-ACCREDITED PROGRAM: For related MFT programs or NON-COAMFTE programs, list the name of the course, the

course number and the name of the institution in which the course was completed.

An official course description must be attached for each course listed.

1. MARRIAGE AND FAMILY STUDIES (9 semester or 13.5 quarter or a combination of these hours)

Course Definition: Courses in this area should be a fundamental introduction to systems theory. The student should learn to

understand family structures and functioning within the social systems framework (including environmental context) and regarding

diverse range of presenting issues (i.e. gender, cultural, substance abuse). Topic areas may include: systems theory, family

development, family subsystems, blended families, gender issues in families, cultural issues in families, etc.

This area must have a major focus from systems theory orientation and encompass the social systems orientation. Survey or overview

courses in which systems in one of several theories covered is not appropriate. Courses in which systems theory is the overarching

framework and other theories are studied in relations to systems theory are appropriate.

Course Name

Course #

College/University

2. MARRIAGE AND FAMILY THERAPY (9 semester or 13.5 quarter or a combination of these hours)

Course Definition: Courses in this area should have a major focus on family systems theory and systemic therapeutic interventions.

This area is intended to provide a substantive understanding of the major theories of systems change, the applied practices evolving

from each theoretical orientation, including diagnosis/assessment of individuals, couples and families. Major theoretical approaches

might include: strategic, structural, object relations, cognitive behavioral, intergenerational, and integrative models of therapy with

individuals, couples, and families.

Course Name

Course #

College/University

3. HUMAN DEVELOPMENT (9 semester or 13.5 quarter or a combination of these hours)

Course Definition: Courses in this area should provide knowledge of individual personality development and its normal and abnormal

manifestations. The student should have relevant course work in human development across the life span, which includes special

issues that affect an individual's development (i.e. culture, gender, and human sexuality). Topic areas may include human

development, child/adolescent development, psychopathology, personality theory, human sexuality, etc. This material should be

integrated with systems concepts. Test and measurement courses are not accepted toward this area.

Course Name

Course #

College/University

PLMHP/PCMSW Application – Page 11

4. PROFESSIONAL STUDIES (3 semester or 4.5 quarter or a combination of these hours)

Course Definition: Courses in this area are intended to contribute to the professional development of the therapist. Areas of study

should include the therapist's legal responsibilities and liabilities, professional ethics relevant to marriage and family issues,

professional values and socialization, and the role of the professional organization, licensure or certification legislation, independent

practice and interpersonal cooperation. Religious ethics courses and moral theology courses are not accepted toward this area.

Course Name

Course #

College/University

5. RESEARCH

(3 semester or 4.5 quarter or a combination of these hours)

Course Definition: Courses in this area should assist students in understanding and performing research. Topic areas may include

research methodology, quantitative methods and statistics. Individual personality and test and measurement courses are not accepted

toward this area.

Course Name

Course #

College/University

PRACTICUM (minimum 6 semester hours or 9 quarter hours, 300 hours of supervised direct client contact with individuals,

couples and families, and of this 300 hours, no more than 150 hours may be with individuals)

Course Name

Course #

College/University

For Office Use Only: Date reviewed: ____________ by: _____

PLMHP/PCMSW Application – Page 12

SECTION H - PROFESSIONAL COUNSELOR COURSEWORK

COMPLETE THIS COURSEWORK INFORMATION IF YOU WILL BE REQUESTING CERTIFICATION AS A PROFESSIONAL COUNSELOR

ACCREDITED CACREP PROGRAM:

If your program is accredited by CACREP, you ARE NOT required to complete the following coursework information.

NON-ACCREDITED CACREP PROGRAM: The following must be completed by applicants applying with a master's degree from

a non-CACREP counseling related field offered by a regionally accredited higher educational institution.

List the name of the course, the course number and the name of the institution in which the course was completed

An official course description must be attached for each course listed.

COUNSELING THEORY (3 semester hours): Course Definition: Includes a study of basic theories principles and techniques of

counseling and their application to professional counseling settings.