Untitled

Florida Board of Mental Health Professions

www.oridasmentalhealthprofessions.gov

Mailing Address:

Florida Department of Health - Board of Mental Health Professions

4052 Bald Cypress Way | Bin C-08

Tallahassee, Florida 32399-3257

Customer Contact Center

(850) 488-0595

Graduate Packet MHC Applicants

The Board of Clinical Social Work, Marriage & Family Therapy and Mental Health Counseling is dedicated to ensuring our

prospective applicants have the most current information related to licensure. This packet is designed to help those individuals

about to graduate or who have recently graduated from a master’s degree program in mental health counseling or a closely related

field from a regionally accredited university or from a mental health counseling program accredited by the Council for the

Accreditation of Counseling and Related Educational Programs (CACREP).

GRADUATE PACKET CONTENTS

3-Step Application Process Guide……………………................ Pg. 2

Registered Intern Licensing Requirements…………............. Pg. 3

Helpful Information About Supervision……………............... Pg. 4

Licensing Laws & Rules……………………………….................... Pg. 6

Board Contacts…………………………………………...................... Pg. 7

Exam Information……………………………………….................... Pg. 8

APPENDIX

Intern Registration Application and Instructions…............. Pg. 9

Education Worksheet…………………………………….................. Pg. 23

Sample Practicum Letter.……….………………………................. Pg. 25

II.

III.

IV.

VI.

ii.

iii.

@FLMentalHealth

Graduating soon or recently graduated? Congratulations! It is time to apply to

become a Registered Mental Health Counselor Intern. Submit your application

today using these simple steps!

01 – Prepare Your Supporting Documents:

 Official Transcript

 Clinical Practicum Letter

 Qualified Supervisor Letter

02 - Apply Online and Pay $150.00 Required Fee: Visit

https://floridasmentalhealthprofessions.gov/licensing/ and choose Registered

Mental Health Counselor Intern then click “Apply Online.” Applications are not

processed until required payment has been received.

Documents You Can Upload to Your

Online Application

Documents You Need to Have Sent

to the Board Office Directly

 Qualified Supervisor Letter

 Clinical Practicum Letter (Non-

CACREP Students Only)

 Official Transcript

03 – Receive Deficiency Letter or Approval: You will receive a written review

of your application from the Application Processing Team within 30 days of the

date you submitted the application with required payment. This review will be sent

to your email if listed on application and mailing address of record.

Deficiency Letter – Applicants will receive an application review in the form of a deficiency

letter outlining the missing items required. Make sure to submit these missing items as soon as

possible. An incomplete application shall expire after 1 year. Incomplete applications will delay

licensure.

Approval Letter: Applicant will receive application review in the form of a letter of approval

including license number and additional information about internship. To expedite your

application, make sure to submit a complete application.

 Transcripts must be sealed to be official.

 Do not send transcripts prior to graduation. A

degree conferred date on transcript is required.

 E-Transcripts: Program sends directly to

[email protected].

 By Mail: Board of CSW/MFT/MHC, 4052

Bald Cypress Way Bin C-08, Tallahassee, FL

32399-3258

LICENSING REQUIREMENTS

To become a registered mental health counselor intern in Florida you must have:

1. OFFICIAL TRANSCRIPT: Complete the Education Worksheet for mental health counseling enclosed to

determine if you have satisfied the coursework requirements for licensure. Transcripts must be sent in the

official sealed envelope from the university or they will not be considered official. Transcripts must be sent in

the official sealed envelope from the university and include a degree conferred date or they will not be

considered official. Transcripts may be sent via email if the program can send official digital transcripts via a

secure transcript clearinghouse and the transcript download link is sent directly to [email protected]. All

other supporting documents should be mailed to the address listed below:

Department of Health

Board of CSW/MFT/MHC

4052 Bald Cypress Way Bin C-08

Tallahassee, FL 32399-3258

2. COURSEWORK: You must either qualify under (a) or (b) below:

(a) Minimum of an earned master’s degree from a mental health counseling program accredited by the Council

for the Accreditation of Counseling and Related Educational Programs (CACREP) that consists of at least 60

semester hours or 80 quarter hours of clinical and didactic instruction, including a course in human sexuality

and a course in substance abuse. Ensure your program is accredited in mental health counseling by visiting

https://www.cacrep.org/. NOTE: CACREP accredited programs that are not mental health counseling

programs do not meet this requirement, i.e., community counseling, school counseling, counselor education.

(b) Minimum of an earned master’s degree from a program related to the practice of mental health counseling

that consists of at least 60 semester hours or 80 quarter hours and meets the following requirements:

i. Minimum of 3 semester hours or 4 quarter hours of graduate-level coursework in each of the following 12

content areas: counseling theories and practice, human growth and development, diagnosis and treatment of

psychopathology, human sexuality, group theories and practice, individual evaluation and assessment, career and

lifestyle assessment, research and program evaluation, social and cultural foundations, counseling in community

settings, substance abuse, and legal, ethical, and professional standards issues. Courses in research, thesis or

dissertation work, practicums, internships, or fieldwork are not applied toward this requirement; AND

ii. The equivalent of at least 1,000 hours of university-sponsored supervised clinical practicum, internship, or field

experience as required in the standards for CACREP accredited mental health counseling programs. This

experience may not be used to satisfy the post-master’s clinical experience requirement. Submit a practicum

letter to the Board Office on University letterhead to satisfy this requirement.

NOTE: You may become a registered intern having met 7 of the 12 course content areas if one of the 7 courses was

in psychopathology. If you do not meet the practicum requirement, the hours may be obtained as a registered

intern and must be documented on the Graduate Practicum Attestation form by your Board approved Qualified

Supervisor. Any remaining courses and practicum hours must be met prior to obtaining licensure as a Mental

Health Counselor.

3. QUALIFIED SUPERVISOR: Applicants must obtain a letter from a Board approved Qualified Supervisor

and submit to the Board Office. The letter may be sent by mail or electronic mail. To submit via electronic

mail, send via email to [email protected]ov. The correspondence must originate from the supervisor,

include the supervisor’s license number and the applicant’s name as it appears on the application, and state that

the supervisor has agreed to provide the applicant with supervision while a registered intern. NOTE: Your

registered intern number will not be issued until the Board has received this information.

HELPFUL INFORMATION ABOUT SUPERVISION

Find A Qualified Supervisor:

Did you know that you can obtain a list of supervisors in your area at any time 24 hours a day 7 days a

week? Simply use the Department’s Public Data Portal located on www.flhealthsource.gov under the

Consumer Services dropdown menu to download a current list of Board approved Qualified Supervisors.

For detailed instructions, use the Licensure Data Download Guide. Obtain a letter from your selected

Qualified Supervisor and send to the Board Office. To submit electronically, simply email your letter to

MQA.491@flhealth.gov.

Before Supervision Begins:

Verify that your intern registration number has been issued by the Department and that the Board Office

has approved your qualified supervisor. Supervision experience will not count towards licensure until the

intern registration number has been issued and the Board has approved your supervisor. To verify that

your license has been issued, visit www.flhealthsource.gov and click “Verify a License.” You will receive

a letter from the Board confirming your qualified supervisor has been approved. Do not begin supervision

until your Qualified Supervisor has been approved by the Board Office.

During Supervision:

Two (2) years of post-master’s supervised experience under the supervision of an approved Qualified

Supervisor is required for full licensure.

The supervision experience must have consisted of:

• At least 100 hours of supervision in no less than 100 weeks;

• 1,500 hours of face-to-face psychotherapy with clients; and,

• One (1) hour of supervision every two weeks.

NOTE: Please see Rule 64B4-2.002, F.A.C., for information regarding group supervision and supervision

by electronic methods.

Need to Change or Add a Qualified Supervisor? Follow the steps below:

STEP ONE: Obtain a letter from your new or additional Qualified Supervisor and send to the Board

Office via email to MQA.491@flhealth.gov. The correspondence must originate from and be signed by

the supervisor, include the supervisor’s license number and the applicant’s name as it appears on the

application, and state that the supervisor has agreed to provide the applicant with supervision while a

registered intern.

STEP TWO: Receive letter from the Board Office stating that your supervisor has been approved and

note the date of approval. Supervision under the new or additional supervisor will not count until he/she

has been approved.

Need to Remove a Qualified Supervisor? Follow the steps below:

STEP ONE: Ask the supervisor you are removing to complete the Verification of Clinical Experience

Form and select “I am no longer providing this intern with supervision.” Please make sure a supervision

end date is listed. For a blank form, visit www.floridasmentalhealthprofessions.gov and select the

Resources tab. The form is available under Forms & Requests.

STEP TWO: Submit a Verification of Clinical Experience Form to the Board Office. The Board will

remove your supervisor from your intern file and place a copy of the required form on file for review

upon submission of a full licensure application.

After Supervision:

Your post-master’s clinical experience hours obtained under supervision must be documented on the

Verification of Clinical Experience Form by the qualified supervisor or they will not count towards

licensure. This form is not required until the intern is ready to submit his/her full licensure application.

Please limit one (1) form per qualified supervisor. For a blank form, visit

www.floridasmentalhealthprofessions.gov and select the Resources tab. The form is available under

Forms & Requests.

NOTE: Registered interns must remain under supervision until fully licensed pursuant to Rule 64B4-

3.008, F.A.C.

LICENSING LAWS AND RULES

Know your laws and rules! It is essential that each prospective applicant review the

laws and rules which govern the profession. All the current laws and rules can be

found online by visiting https://floridasmentalhealthprofessions.gov/resources/.

Be prepared for full licensure! Take an Initial 8-hour Florida Laws and Rules

course listed on www.cebroker.com and you will satisfy your laws and rules

requirement for licensure. Simply submit a copy of your certificate of completion

to MQA.4[email protected]ov and you’ve already completed one step of your full

licensure application process.

Florida Statutes:

Chapter 491: 491, Clinical, Counseling, and Psychotherapy Services

Chapter 456: Health Professions and Occupations: General Provisions

Chapter 120: Administrative Procedure Act

Chapter 39: Proceedings Related to Children

Chapter 90: Evidence Code

Chapter 394: Mental Health

Chapter 397: Substance Abuse Services

Chapter 415: Adult Protective Services

Florida Administrative Code (F.A.C.) Rules:

Chapter 64B4: Board of Clinical Social Work, Marriage & Family

Therapy & Mental Health Counseling

Chapter 64B25-28: Certified Master Social Workers

BOARD CONTACTS

Customer Contact Center

Monday – Friday

8:00 a.m. to 6:00 p.m. ET

(850) 488-0595

Mailing Address:

Department of Health

Board of Mental Health

Professions

4052 Bald Cypress Way

Bin C-08

Tallahassee, FL 32399-3258

Board Office

8:00 a.m. to 5:00

p.m. ET

(850) 245-4

292

FAX: 850-

413-6982

Applications and Fees

ONLY:

Department of Health

Board

Mental Health

Professions

P.O. Box 6330

Tallahassee, FL 32314-6330

EXAM INFORMATION

To become a Licensed Mental Health Counselor, you will need to successfully

pass the National Clinical Mental Health Counseling Examination (NCMHCE)

offered by the National Board of Certified Counselors Center for Credentialing and

Education (CCE).

Board Approval Required Prior to Scheduling Exam? No. You can schedule your

exam at any time. You do not have to be a registered intern to schedule. Follow

the steps below:

Step 1 – Apply to CCE to take the NCMHCE by submitting the CCE Exam

Application Form and your official transcript.

NOTE: You must have a master’s degree in mental health counseling or related to

the practice of mental health counseling from a regionally accredited institution

before you are permitted to take the examination.

Step 2 – After passing the examination, your transcript and scores will be

forwarded to the FL Board 4 to 6 weeks after exam date. There is no need to

submit unofficial score report to the Board Office.

CCE Contact Information

Website: https://www.nbcc.org/Search/StateBoardDirectory/fl

Phone: (336) 547-0607

Fax: (336) 547-0017

Email: nbc[email protected]rg

Rule 64B4-3.0085

DH-MQA 1175 (Revised 11/18)

DEPARTMENT OF HEALTH

Board of Clinical Social Work,

Marriage and Family Therapy and

Mental Health Counseling

Intern Registration Application

and

Instructions

Department of Health

Florida Board of CSW/MFT/MHC

4052 Bald Cypress Way, C-08

Tallahassee, FL 32399-3258

Telephone: (850) 245-4474

www.floridasmentalhealthprofessions.gov

Email: MQA.491@flhealth.gov

Rule 64B4-3.0085

DH-MQA 1175 (Revised 11/18)

INTERN REGISTRATION APPLICATION INSTRUCTIONS

STEP 1

COMPLETING THE APPLICATION FOR INTERN REGISTRATION [5 PAGES]

Section I – Applicant Profile Data:

 List your legal name as it should appear on your license.

 Your mailing address is used whenever you are sent documents, renewals, licenses, etc. from the

Department of Health. When you become a registered intern, your name, license number and

practice location address will be shown on our Internet License Verification.

 If you do not want your mailing address on the website, fill in the “practice location address” on the

Intern Registration Application as you want it to appear on the website. If you only provide one

address, it will be used for both the mailing address and the practice location address. Please note

that the practice location address must be a street address.

 Answer the question concerning name change(s).

 Indicate the registration category for which you are applying by checking one box. If you wish to

apply for more than one category, you must submit a separate application, application fee, and

supporting documents.

 Check appropriate box or fill in requested information on remainder of Section I.

Section II - Post-Secondary Education Background:

 List the degree(s) you hold, beginning at the master’s level. Identify your program of study at the

college or university where you received this degree. Include the month, day, and year in which the

degree was received. List any schools where you completed additional graduate or post-graduate

coursework.

Section III - Qualified Supervisor(s):

 List the qualified supervisor(s) who will be providing individual and/or group supervision, their license

title, Florida license number, and the year they received their license. You may attach additional

sheets, if necessary.

 Each supervisor you list must provide our office with written correspondence. This correspondence

must state that the supervisor has agreed to provide you with supervision while you are a registered

intern. The correspondence may be faxed or e-mailed, but it must originate from the supervisor.

Your file will not be complete until we have received this documentation.

Section IV - Applicant History – General:

 If you answer “yes”, you must provide complete details and certified copies of court

records/dispositions.

Section V - Applicant History – Professional:

 If you answer "yes" to any question in this section, you must provide complete details. A "yes"

answer does not mean the application will be denied, however, failure to provide the correct

information may result in licensure denial.

Section VI – Applicant History Pursuant to Section 456.0635, Florida Statutes:

 IMPORTANT NOTICE: Applicants for licensure, certification or registration and candidates for

examination may be excluded from licensure, certification or registration if their felony conviction falls

into certain timeframes as established in Section 456.0635(2), Florida Statutes.

Rule 64B4-3.0085

DH-MQA 1175 (Revised 11/18)

Section VII - Certification:

 Your signature is required. By signing you are attesting that you have provided true and correct

information on the application and supporting documents, as well as having read the laws and rules.

Section VIII – Social Security Number: Your social security number is required.

Section IX – Applicant History – Health:

 The Board reviews each applicant's history to determine that the applicant is able to practice the

profession with reasonable skill or competence. If you answer "YES" to any of the questions in this

section, you must submit a current mental health status report from a licensed mental health

professional, wherein this professional practitioner opines that you are able to practice with

reasonable skill and safety to patients or clients.

 The report should include: a description and summary of the diagnosis, onset, course of treatment,

medications, inpatient treatments, outpatient treatments, group settings, factors which have triggered

setbacks, compliance with treatment, prognosis, and recommendations for continued treatment.

STEP 2

EDUCATION WORKSHEET: CSW, MFT OR MHC

 Locate the worksheet for the profession for which you are applying: CSW or MFT or MHC. Write

your name at the top and complete the form.

 The education worksheet must be filled out completely in order for the Board to determine if your

education meets the requirements of Chapter 491, F.S. All coursework listed on this worksheet

must be supported by official transcripts and course descriptions.

STEP 3

PRACTICUM/INTERNSHIP/FIELD PLACEMENT VERIFICATION

 Contact your university and request that an official of the university submit a letter, on university

letter head, that verifies you completed at least one supervised clinical practicum, internship, or

field experience which meets the requirements outlined in the corresponding law for your profession.

This letter may be mailed to the board office by the university. If the letter accompanies your

application, it must be in a sealed envelope bearing the signature of the official across the flap.

 The practicum, internship, or field experience requirement is part of the educational requirements

for your profession. This requirement must be met for your education to be certified complete.

 The education worksheet for your profession includes the practicum/internship/field placement

requirement. Read the appropriate definition for your profession in the statute section listed

below:

CSW: 491.005(1)(b)2.a., F.S. and s. 491.005(2)(b), F.S.

MFT 491.005(3)(b)1.d., F.S.

MHC 491.005(4)(b)1.c., F.S.

 You may access the Florida Statutes through our website at

http://floridasmentalhealthprofessions.gov and click on “Resources”.

STEP 4

TRANSCRIPTS

 You must request an official transcript from the regionally accredited institution(s) from which you

received your degree or have taken coursework. These transcripts must be sent directly to the board

office from the registrar's office of the institution or they will not be considered official. You may

submit your official transcript with your application, but only if the official transcript is in a sealed

envelope with a school official’s signature across the flap.

 If the course title on your transcript does not clearly identify the content of the coursework, a course

description or syllabus will be required.

Rule 64B4-3.0085

DH-MQA 1175 (Revised 11/18)

 FOREIGN EDUCATION for CSW Intern Applicants

If you received your social work degree from a program outside the U.S. or Canada, documentation

must be received that it was determined to have been a program equivalent to programs approved by

the Council on Social Work Education by the Foreign Equivalency Determination Service of the

Council on Social Work Education.

 FOREIGN EDUCATION for MFT and MHC Intern Applicants

For the Board to consider education completed outside the U.S. or Canada, documentation must be

received which verifies the institution at which the education was completed was equivalent to a

regionally accredited U.S. institution and the coursework met the content and credit hour requirement

for graduate level coursework in the U.S. It is the applicant's responsibility to obtain an evaluation

from a recognized foreign equivalency determination service that documents the acceptability of the

coursework. The board office must receive an original evaluation mailed directly from the educational

evaluation service.

 DOCUMENTS IN A FOREIGN LANGUAGE – A certified translator who is not related to the applicant

must translate any document in a foreign language into ENGLISH.

STEP 5

MAKE COPIES OF ALL DOCUMENTS THEN MAIL THE ORIGINALS TO THE BOARD OFFICE

MAILING THE INFORMATION AND REQUIRED FEE OF $150.00

 Make your cashier’s check or money order payable to the Department of Health and securely attach

to the application.

 You may pay by credit or debit card if you submit your application online at www.flhealthsource.com

and click on “Apply for a License”.

 Mail the intern registration application and nonrefundable application fee of $150.00 to:

BOARD OF CSW, MFT, MHC

P O BOX 6330

TALLAHASSEE, FL 32314-6330

 Any additional documentation that you mail, or others mail on your behalf, should be sent to the

address shown below. Any variation or abbreviation of this address may cause a delay in

processing. If information is mailed from a source other than the applicant, the applicant’s full name

must appear on the correspondence or documentation.

BOARD OF CSW, MFT, MHC

4052 BALD CYPRESS WAY, BIN #C08

TALLAHASSEE, FL 32399-3258

Rule 64B4-3.0085

DH-MQA 1175 (Revised 11/18)

DEPARTMENT OF HEALTH

Board of Clinical Social Work

Marriage and Family Therapy

& Mental Health Counseling

Intern

Registration

Application

Section I APPLICANT PROFILE DATA (TYPE OR PRINT NEATLY IN BLACK INK)

Name

Last First Middle

Mailing

Address

Street Address or P.O. Box Apt. No.

City State Zip

*Practice

Location

Address

Street Address Required Apt. No.

City State Zip

Date of birth:

_________/_________/___________

Have you ever changed your name through marriage or through action

of a court, or have you ever been known by any other name?

 YES  NO If “YES” list name(s)

REGISTRATION CATEGORY - CHECK ONE:

 CLINICAL SOCIAL WORKER Intern (5207)

 MARRIAGE & FAMILY THERAPIST Intern (5208)

 MENTAL HEALTH COUNSELOR Intern (5209)

Primary Telephone:

area code ( )

Business Telephone:

area code ( )

E-Mail Address (Optional. Will be public record if provided.):

May we send correspondence through e-mail?

 YES  NO

Gender:  Male  Female

Equal Opportunity Data: We are required to ask that you furnish the following information as part of your voluntary compliance with Section 2,

Uniform Guidelines on Employee Selection Procedure (1978) 43 FR 38296 (August 25, 1978). This information is gathered for statistical and

reporting purposes only and does not in any way affect your candidacy for licensure.

SEX:



Male



Female U.S. Citizen:



Yes 

RACE:



White



Black



Asian/Pacific



Hispanic



Other

SECTION II POST-SECONDARY EDUCATION BACKGROUND

DEGREE

(If Applicable)

MAJOR

COLLEGE OR UNIVERSITY

DEGREE

CONFERRED DATE

/ /

For clinical social work applicants only. Were you an advanced standing student?  YES  NO

Page 1 of 5

Rule 64B4-3.0085

DH-MQA 1175 (Revised 11/18)

APPLICANT NAME ___________________________________________________

SECTION III QUALIFIED SUPERVISOR(S)

*NAME

LICENSE TITLE

FLORIDA LICENSE NO.

YEAR

You must provide our office with written correspondence from each supervisor you list. The correspondence must state

that the supervisor has agreed to provide you with supervision while you are a registered intern.

SECTION IV APPLICANT HISTORY – GENERAL

Have you ever been convicted of, or entered a plea of guilty, nolo contendere, or no contest

to a crime in any jurisdiction other than a minor traffic offense? You must include all

misdemeanors and felonies, even if adjudication was withheld by the court so that you would

not have a record or conviction. Driving under the influence or driving while impaired is not a

minor traffic offense for purposes of this question.

If you answered “Yes” to the question above you are required to send the following

items:

 Self Explanation describing in detail the circumstances surrounding each offense;

including dates, city and state, charges and final results.

 Final Dispositions and Arrest Records for all offenses. The Clerk of the Court in the

arresting jurisdiction will provide you with these documents. Unavailability of these documents

must come in the form of a letter from the Clerk of the Court.

 Completion of Sentence Documents. You may obtain documents from the Department

of Corrections. The report must include the start date, end date and that the conditions were

met.

YES NO

SECTION V APPLICANT HISTORY - PROFESSIONAL

A. Have you ever been denied a psychotherapy or counseling-related license or the

renewal thereof in any state?

YES NO

B. Have you ever been denied the right to take a psychotherapy or counseling-related

licensure examination?

YES NO

C. Have you ever had a license to practice any profession revoked, suspended, or

otherwise acted against in a disciplinary proceeding in any state?

YES NO

D. Is there currently pending, in any jurisdiction, a complaint against your professional

conduct or competency in a psychotherapy or counseling-related profession?

YES NO

E. Have you ever been involved in, reprimanded for or disciplined by an employer or

educational institution for misconduct including:

1. Acts of dishonesty, fraud, or deceit

2. Lying on a resume or misrepresentation

3. Academic misconduct, including acts such as cheating or plagiarism

4. Theft

5. Sexual harassment

1.YES NO

2.YES NO

3.YES NO

4.YES NO

5.YES NO

If you answered "YES" to any question in Section V, you must provide the Board complete details.

Page 2 of 5

Rule 64B4-3.0085

DH-MQA 1175 (Revised 11/18)

APPLICANT NAME ___________________________________________________

SECTION VI APPLICANT HISTORY PURSUANT TO SECTION 456.0635, FLORIDA STATUTES

IMPORTANT NOTICE: Applicants for licensure, certification or registration and candidates for examination may be

excluded from licensure, certification or registration if their felony conviction falls into certain timeframes as

established in Section 456.0635(2), Florida Statutes. If you answer YES to any of the following questions, please

provide a written explanation for each question including the county and state of each termination or conviction, date

of each termination or conviction, and copies of supporting documentation. Supporting documentation includes court

dispositions or agency orders where applicable.

1. Have you been convicted of, or entered a plea of guilty or nolo contendere to, regardless of

adjudication, a felony under Chapter 409, F.S. (relating to social and economic assistance),

Chapter 817, F.S. (relating to fraudulent practices), Chapter 893, F.S. (relating to drug abuse

prevention and control) or a similar felony offense(s) in another state or jurisdiction?

(If you responded “no”, skip to # 2.)

 YES  NO

a. If “yes” to 1, for the felonies of the first or second degree, has it been more than 15 years from

the date of the plea or conviction, and completion of any sentence or subsequent period of

probation?

 YES  NO

b. If “yes” to 1, for the felonies of the third degree, has it been more than 10 years from the date

of the plea, sentence and completion of any subsequent probation? (This question does not

apply to felonies of the third degree under Section 893.13(6)(a), Florida Statutes).

 YES  NO

c. If “yes” to 1, for the felonies of the third degree under Section 893.13(6)(a), Florida Statutes,

has it been more than 5 years from the date of the plea, sentence and completion of any

subsequent probation?

 YES  NO

d. If “yes” to 1, have you successfully completed a drug court program that resulted in the plea

for the felony offense being withdrawn or the charges dismissed? (If “yes”, please provide

supporting documentation).

 YES  NO

Have you been convicted of, or entered a plea of guilty or

nolo contendere to, regardless of

adjudication, a felony under 21 U.S.C. ss. 801-970 (relating to controlled substances) or 42

U.S.C. ss. 1395-1396 (relating to public health, welfare, Medicare and Medicaid issues)?

(If “No”, do not answer 2a.)

 YES  NO

a. If “yes” to 2, has it been more than 15 years before the date of application since the sentence

and any subsequent period of probation for such conviction or plea ended?

 YES  NO

3. Have you ever been terminated for cause from the Florida Medicaid Program pursuant to

Section 409.913, Florida Statutes?

(If “No”, do not answer 3a.)

 YES  NO

a. If you have been terminated but reinstated, have you been in good standing with the Florida

Medicaid Program for the most recent five years?

 YES  NO

4. Have you ever been terminated for cause, pursuant to the appeals procedures established by

the state, from any other state Medicaid program?

(If “No”, do not answer 4a or 4b.)

 YES  NO

a. Have you been in good standing with a state Medicaid program for the most recent five years?

 YES  NO

b. Did the termination occur at least 20 years before the date of this application?

 YES  NO

5. Are you currently listed on the United States Department of Health and Human Services Office

of Inspector General's List of Excluded Individuals and Entities?

 YES  NO

Page 3 of 5

Rule 64B4-3.0085

DH-MQA 1175 (Revised 11/18)

APPLICANT NAME ___________________________________________________

SECTION VII CERTIFICATION

I understand that it is my duty and responsibility as an applicant for licensure to

supplement my application after it has been submitted if and when any material change in

circumstances or conditions occur which might affect the Board’s decision concerning my

eligibility for registration or licensure. Such supplement is required by sections 456.072,

F.S., and 456.013(1)(2), F.S. Failure to do so may result in disciplinary action by the

Board including denial of licensure.

I hereby authorize all hospitals, institutions, or organizations, personal physicians,

employers (past or present), business and professional associates (past or present), and

all government agencies and instrumentalities (local, state, federal, or foreign) to release

to the Department of Health any information, files, or records requested by the Department

in connection with the processing of this application. I further authorize the Department to

release to the organizations, individuals, and groups listed above any information which is

material to my application.

I have carefully read the questions in the foregoing application and have answered them

completely, without reservations of any kind. I declare that these statements are true and

correct and recognize that providing false information may result in disciplinary action

against my license pursuant to s. 456.067, F.S., or criminal penalties pursuant to s.

775.082, s. 775.083, or s. 775.084, F.S. Should I furnish any false information on this

application, I hereby acknowledge that such act may constitute cause for denial,

suspension, or revocation of any license to practice in the State of Florida.

I hereby acknowledge that I have read the regulations in Chapter 491, F.S., and related

rules. I understand that I am under a continuing obligation to keep informed of any

changes to Chapter 491, F.S., and related rules.

I understand that pursuant to section 456.013(1)(a), F.S., an incomplete application shall

expire 1 year after initial filing.

____________________________________________ ____________________

Applicant Signature Date

Page 4 of 5

Rule 64B4-3.0085

DH-MQA 1175 (Revised 11/18)

CONFIDENTIAL AND EXEMPT FROM

PUBLIC RECORDS DISCLOSURE

DEPARTMENT OF HEALTH

Board of Clinical Social Work, Marriage and Family Therapy

and Mental Health Counseling

Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically

required by federal statute. In this instance, Social Security numbers are mandatory pursuant to Title 42 USCA §

666 (a)(13); and Sections 456.013, 409.2577, and 409.2598, Florida Statutes. Social Security numbers are used to

allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with

child support obligations. Social Security numbers must also be recorded on all professional and occupational

license applications and will be used for licensee identification pursuant to the Personal Responsibility and Work

Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub. L 193, Section 317.

Name: ________________________________________________________________

Last First Middle

VIII. Social Security Number: ____________________________________

IX. APPLICANT HISTORY – HEALTH

A. Do you have any condition that currently impairs your ability to practice your

profession with reasonable skill and safety?

 YES  NO

B. Are you using medications, other drugs, narcotics, or intoxicating chemicals that

impair your ability to practice your profession with reasonable skill and safety?

 YES  NO

If you answered "yes" to either of the above questions, please provide a letter from a licensed health care

practitioner, who is qualified by skill and training to address your condition, which explains the impact

your condition may have on your ability to practice your profession with reasonable skill and safety, and

stating either that you are safe to practice your profession without restriction or indicating what

restrictions are necessary. If necessary, you may attach additional sheets. Documentation must be

current within the last year. If you fail to disclose the information requested in this section, your

application may be denied.

Page 5 of 5

Rule 64B4-3.0085

DH-MQA 1175 (Revised 11/18)

EDUCATION WORKSHEET

CLINICAL SOCIAL WORK

Print clearly or type the following information.

APPLICANT NAME _____________________________________________________________

I. GENERAL INFORMATION

You are required to complete 24 semester hours or 32 quarter hours of graduate level coursework in theory of

human behavior and practice methods as courses in clinically oriented services within an accredited school of

social work program. (Only one research course may be counted towards the coursework requirement). Do

NOT list fieldwork. Course numbers and titles should be listed as they appear on your official transcripts. You

must submit a course description photocopied from a school catalog or a course syllabus for all courses listed

below. If you were admitted to an advanced standing program, an official of the school which awarded your

master’s degree in social work must provide a letter, on university letterhead, verifying the specific courses

completed at the baccalaureate level, which were used to waive or exempt completion of similar courses at the

graduate level.

SCHOOL

COURSE

NUMBER

COURSE TITLE

CREDIT

HOURS

II. PSYCHOPATHOLOGY

List the graduate level psychopathology course you completed within an accredited school of social work

program. You must submit a course description photocopied from a school catalog or a course syllabus for

the course listed.

SCHOOL

COURSE

NUMBER

COURSE TITLE

CREDIT

HOURS

III. ADVANCED SUPERVISED FIELD PLACEMENT

You are required to complete a supervised field placement which was part of your advanced concentration in

direct practice, during which you provided clinical services directly to clients. An official of the school (Dean,

Department Chair) which awarded your graduate degree must provide a letter on university letterhead

verifying: 1) that the supervised field placement was completed during the master’s or doctorate program; and

2) the setting in which you provided clinical services directly to clients.

ADVANCED SUPERVISED

FIELD PLACEMENT

COURSE TITLE

COURSE

NUMBER

SCHOOL

DATES

Rule 64B4-3.0085

DH-MQA 1175 (Revised 11/18)

EDUCATION WORKSHEET

MARRIAGE AND FAMILY THERAPY

Print clearly or type the following information.

APPLICANT NAME __________________________________________________________

I. COURSEWORK VERIFICATION

You must indicate the graduate level course(s) you completed that satisfy the educational

requirement in the content areas listed. Course numbers and titles should be listed as they appear

on your official transcripts. If the course title on your transcript does not clearly identify the content

of the coursework, a course description or syllabus may be required.

You are required to complete 36 semester hours or 48 quarter hours of graduate level coursework.

Each of the following content areas must have a minimum of 3 semester hours or 4 quarter

hours in graduate level coursework.

CONTENT AREA

SCHOOL

COURSE

NUMBER

COURSE TITLE

Dynamics of

Marriage & Family

Systems

1. ______________

2. ______________

1. ____________

2. ____________

1. ___________________________

2. ___________________________

Marriage Therapy

& Counseling

Theory &

Techniques

1. ______________

2. ______________

1. ____________

2. ____________

1. ___________________________

2. ___________________________

Family Therapy &

Counseling Theory

& Techniques

1. ______________

2. ______________

1. ____________

2. ____________

1. ___________________________

2. ___________________________

Individual Human

Development

Theories

Throughout the

Life Cycle

1. ______________

2. ______________

1. ____________

2. ____________

1. ___________________________

2. ___________________________

Personality Theory

or General

Counseling Theory

& Techniques

1. ______________

2. ______________

1. ____________

2. ____________

1. ___________________________

2. ___________________________

Psychopathology

1. ______________

2. ______________

1. ____________

2. ____________

1. ___________________________

2. ___________________________

Human Sexuality

Theory &

Counseling

Techniques

1. ______________

2. ______________

1. ___________

2. ___________

1. ___________________________

2. ___________________________

Rule 64B4-3.0085

DH-MQA 1175 (Revised 11/18)

Psychosocial

Theory

1. ______________

2. ______________

1. ___________

2. ___________

1. ___________________________

2. ___________________________

Substance Abuse

Theory &

Counseling

Techniques

1. ______________

2. ______________

1. ___________

2. ___________

1. ___________________________

2. ___________________________

The following courses must be a minimum of one graduate-level course of 3 semester or

4 quarter hours.

Legal, Ethical,

Professional Standards

Issues in the Practice of

Marriage & Family

Therapy

1. ______________

1. ___________

1. ___________________________

Diagnosis, Appraisal,

Assessment, and

Testing for Individual or

Interpersonal Disorder

or Dysfunction

1. ______________

1. ___________

1. ___________________________

Behavioral Research

(Course must focus on

the interpretation and

application of research

data as it applies to

clinical practice)

1. ______________

1. ___________

1. ___________________________

II. SUPERVISED CLINICAL PRACTICUM, INTERNSHIP, FIELD EXPERIENCE

You are required to complete a minimum of one supervised practicum, internship, or field experience in a

marriage and family counseling setting, during which you provided 180 direct client contact hours of marriage

and family services under the supervision of a qualified supervisor.

This requirement may be met by a supervised practice experience which took place outside the academic

arena but is certified (by the University) as equivalent to a graduate-level practicum with 180 direct client

contact hours of marriage and family services offered within an academic program of an accredited college

or university. An official of the school (Dean, Department Chair) which awarded your graduate degree must

provide a letter on university letterhead verifying that the supervised practicum was completed in a

marriage and family counseling setting, during which you provided 180 direct client contact hours

of marriage and family services.

The practicum letter should also include the following:

a. Course Title of Practicum/Internship/Field Experience

b. Course Number

c. Setting (was it a marriage and family counseling setting)

d. Total Number of Direct Client Contact Hours in Marriage and Family Services

Rule 64B4-3.0085

DH-MQA 1175 (Revised 11/18)

EDUCATION WORKSHEET

MENTAL HEALTH COUNSELING

Print clearly or type the following information:

APPLICANT NAME _______________________________________________________________

If the program you graduated from was not accredited by the Council for Accreditation of Counseling and

Related Education Programs (CACREP) or if the program you graduated from was a CACREP

accredited program that was not mental health counseling, then sections I, II, and III apply to you.

(There are CACREP accredited programs in community counseling; marital, couple, and family

counseling; and school counseling, for example.) If you graduated from a CACREP mental health

counseling program, then section IV applies to you

I. GENERAL INFORMATION

Your overall degree program must be a minimum of 60 semester hours or 80 quarter hours. Within

the degree program, you’ll be required to complete 3 semester hours or 4 quarter hours of

individualized graduate level coursework at an accredited college or university in each of the content

areas listed below. Course numbers and titles should be listed as they appear on your official

transcripts. If the course title on your transcript does not clearly identify the content of the

coursework, a course description or syllabus WILL be required.

II. COURSEWORK VERIFICATION

You must indicate below the graduate level course you completed that satisfies the education

requirement in the specific content area. You must have a minimum of 3 semester hours or

4 quarter hours to satisfy each content area.

Content Area

School

Course Number

Course Title

Counseling Theories

and Practice

Human Growth and

Development

Diagnosis and Treatment

of Psychopathology

Human Sexuality

Group Theories and

Practice

Individual Evaluation

and Assessment

Career and Lifestyle

Assessment

Research and Program

Evaluation

Social and Cultural

Foundations

Counseling in Community

Settings

Substance Abuse

Legal, Ethical &

Professional Standards

To qualify for mental health counseling intern registration, an applicant must have

completed a minimum of 7 of the above required course content areas, one of which must

be a course in psychopathology or abnormal psychology. Please see s. 491.005(4)(c), F.S.

Rule 64B4-3.0085

DH-MQA 1175 (Revised 11/18)

III. UNIVERSITY SPONSORED SUPERVISED CLINICAL PRACTICUM, INTERNSHIP OR FIELD

EXPERIENCE.

You must complete at least 1,000 hours of university-sponsored supervised clinical practicum, internship,

or field experience as required in the accrediting standards of CACREP for mental health counseling

programs.

The accrediting standards of CACREP for these hours are:

 At least 280 of these hours must be in direct service with actual clients that contributes to the

development of counseling skills, including experience leading groups

 An average of one hour per week of individual and/or triadic supervision

 The opportunity for the applicant to become familiar with a variety of professional activities and

resources in addition to direct service (e.g., record keeping, assessment instruments, supervision,

information and referral, in-service and staff meetings)

 The opportunity for the applicant to develop program-appropriate audio/video recordings for use

in supervision or to receive live supervision of the applicant’s interactions with clients

 Evaluation of the applicant’s counseling performance throughout the practicum/internship,

including a formal evaluation after the completion of the practicum/internship hours

An official of the school (Dean, Department Chair) which awarded your graduate degree must provide a

letter on university letterhead verifying that the supervised practicum/internship was completed in

accordance with CACREP standards. The practicum letter should also include the following:

a. Course Title(s) of Practicum/Internship/Field Experience

b. Course Number(s)

c. School or Site Where Experience was Completed

d. Dates of Practicum/Internship or Field Experience

e. Total Number of Clock Hours Completed

If you did not complete a minimum of 1,000 hours in your master’s program, you may complete the

practicum/internship requirement outside the university setting. When completing practicum/internship

hours outside the university setting, the above listed CACREP standards must be met. In addition, you

must be supervised by a qualified supervisor. If you have fewer than 1,000 practicum/internship hours

when you register as an intern, you will be sent a form for documenting these hours outside the

university setting. This form must be completed and signed by your qualified supervisor. You cannot

begin your post-master’s supervision experience until you meet the 1,000 hours of practicum/internship

requirement.

*****************************************************************************************************************

IV. If you graduated from a mental health counseling program accredited by CACREP, your overall

degree program must be a minimum of 60 semester hours or 80 quarter hours, including a course in

human sexuality and a course in substance abuse.

Indicate below the graduate level course you completed that satisfies the two specific content areas.

You must have a minimum of 3 semester hours or 4 quarter hours in each content area.

Content Area

School

Course Number

Course Title

Human Sexuality

Substance Abuse

Rule 64B4-3.001

DH-MQA 1174 (Revised 07/16)

EDUCATION WORKSHEET

MENTAL HEALTH COUNSELING

PPLICANT

AME

__________________________________________________________

If the program you graduated from was not accredited by the Council for Accreditation of Counseling and

Related Education Programs (CACREP) or if the program you graduated from was a CACREP

accredited program that was not mental health counseling, then sections I, II, and III apply to you.

(There are CACREP accredited programs in community counseling; marital, couple, and family

counseling; and school counseling, for example.) If you graduated from a CACREP mental health

counseling program, then section IV applies to you

I. GENERAL INFORMATION

Your overall degree program must be a minimum of 60 semester hours or 80 quarter hours. Within

the degree program, you’ll be required to complete 3 semester hours or 4 quarter hours of

individualized graduate level coursework at a regionally accredited institution in each of the content

areas listed below. Course numbers and titles should be listed as they appear on your official

transcripts. If the course title on your transcript does not clearly identify the content of the

coursework, a course description or syllabus will be required.

II. COURSEWORK VERIFICATION

You must indicate below the graduate level course you completed that satisfies the education

requirement in the specific content area. You must have a minimum of 3 semester hours or

4 quarter hours to satisfy each content area.

Content Area School Course Number Course Title

Counseling Theories and

Practice

Human Growth and

Development

Diagnosis and Treatment

of Psychopathology

Human Sexuality

Group Theories and

Practice

Individual Evaluation and

Assessment

Career and Lifestyle

Assessment

Research and Program

Evaluation

Social and Cultural

Foundations

Counseling in Community

Settings

Substance Abuse

Legal, Ethical &

Professional Standards

Rule 64B4-3.001

DH-MQA 1174 (Revised 07/16)

III. UNIVERSITY SPONSORED SUPERVISED CLINICAL PRACTICUM, INTERNSHIP OR

FIELD EXPERIENCE.

You must complete at least 1,000 hours of university-sponsored supervised clinical practicum, internship,

or field experience as required in the accrediting standards of CACREP for mental health counseling

programs.

The accrediting standards of CACREP for these hours are:

 At least 280 of these hours must be in direct service with actual clients that contributes to the

development of counseling skills, including experience leading groups

 An average of one hour per week of individual and/or triadic supervision

 The opportunity for the applicant to become familiar with a variety of professional activities and

resources in addition to direct service (e.g., record keeping, assessment instruments, supervision,

information and referral, in-service and staff meetings)

 The opportunity for the applicant to develop program-appropriate audio/video recordings for use

in supervision or to receive live supervision of the applicant’s interactions with clients

 Evaluation of the applicant’s counseling performance throughout the practicum/internship,

including a formal evaluation after the completion of the practicum/internship hours

An official of the school (Dean, Department Chair) which awarded your graduate degree must provide a

letter on university letterhead verifying that the supervised practicum/internship was completed in

accordance with CACREP standards. The practicum letter should also include the following:

a. Course Title(s) of Practicum/Internship/Field Experience

b. Course Number(s)

c. School or Site Where Experience was Completed

d. Dates of Practicum/Internship or Field Experience

e. Total Number of Clock Hours Completed

This requirement may be met by supervised practice experience which took place outside the academic

arena that met the CACREP standards and was under the supervision of a qualified supervisor or the

equivalent.

*****************************************************************************************************************

IV.

If you graduated from a mental health counseling program accredited by CACREP, your overall

degree program must be a minimum of 60 semester hours or 80 quarter hours, including a course in

human sexuality and a course in substance abuse.

Indicate below the graduate level course you completed that satisfies the two specific content areas.

You must have a minimum of 3 semester hours or 4 quarter hours in each content area.

Content Area School Course Number Course Title

Human Sexuality

Substance Abuse

SAMPLE PRACTICUM LETTER

PROGRAM LETTERHEAD/LOGO

Date

Board of Clinical Social Work, Marriage & Family Therapy and Mental Health Counseling

4052 Bald Cypress Way

Bin #C-08

Tallahassee, FL 32399

Dear Sir or Madam:

This is to confirm that (NAME OF APPLICANT), (FILE NUMBER OR SOCIAL SECURITY NUMBER)

was awarded a master’s degree on (DEGREE CONFERRED DATE). He/she completed (TOTAL

NUMBER OF HOURS) hours of university sponsored clinical practicum, field experience, or

internship. The hours were completed in courses (PREFIX AND TITLE OF COURSE).

If you have any additional questions, please contact me at (PHONE NUMBER OR EMAIL

ADDRESS).

Sincerely,

(PROGRAM OFFICIAL)

(TITLE OF PROGRAM OFFICIAL)

PROGRAM INFORMATION/LETTERHEAD FOOTER