***FOR OFFICE USE ONLY***
***FOR OFFICE USE ONLY***
Mental Health Couns. Checklist
Application Approved:
License Number:
Endorsement
Examination
App. & Fee
Date:__________ Check______
Birth Certificate/Legal Entry
Photo
Transcript
Statements of Supervised Practice
Supervisor’s Resume(s)
Verification of Supervisor’s OOS Lic.
Score/Certification from NBCC
2 Reference Letters
License Verif. from Other State(s)
Issue Date:
Signature of Board Administrator
ID#:
Receipt #:
Rhode Island
Board of Mental Health Counselors and
Marriage & Family Therapists
Room 104
3 Capitol Hill
Providence, RI 02908-5097
Instructions and Application For
Mental Health Counselor
Name
License #
License As A
by
Examination
Endorsement
Applicant - Print Name (First/MI/Last)
Phone: (401) 222-2828
TTY/TDD: (800) 745-5555
Fax: (401) 222-1272
Revised 09/23/2011 jcp
GENERAL INFORMATION
Enclosures
The following materials and information should be enclosed within this application packet:
Application Process Overview........................................................................................................... 3
Instructions for Completing Application..............................................................................................4
Application Materials
Application.............................................................................................................................. 5-8
Application Checklist.............................................................................................................. 9
Statement of Supervised Practice Form................................................................................10
Core Curriculum Coursework Requirement Form.................................................................11
Interstate Verification Form - Other State License(s).............................................................12
Licensure Requirements
U.S. Graduates
•
Application Fee of $460.00 (NON-REFUNDABLE).
•
Recent passport type photograph (Approximately 2” X 2” head and shoulder view).
•
Birth certificate (original or a copy notarized as being a true copy of the original), or if born
outside the United States, proof of citizenship or lawful alien status, (original or a copy notarized as
being a true copy of the original).
•
Official transcript from an accredited College or University (60 credits required).
•
Two (2) original statements of good moral character from 2 unrelated people, dated no later than six (6)
months previous. Letters must be signed, dated and have a return address.
•
Score/Certification of NCMHCE sent directly from the National Board of Certified Counselors (NBCC).
•
Statement(s) of Supervised Practice (Original’s Only) (including supervisor’s resume) (page 10).
•
License Verifications from the state(s) in which applicant holds or has held a license (page 12).
Rules and Regulations/Laws
To obtain the Rules and Regulations for your profession visit the A-Z list on the Topics & Programs page at the
following web site. From the list click on the letter for your profession.
http://www.health.ri.gov/atoz/
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 2
APPLICATION PROCESS OVERVIEW
The licensure process in the State of Rhode Island is conducted by the Rhode Island Department of Health
(HEALTH), Office of Health Professionals Regulation, and the Rhode Island Board of Mental Health Counselors
and Marriage & Family Therapists (Board).
Application Process
Application for license to practice as a Mental Health Counselor shall be made on forms provided by the Division
of Professional Regulation, which shall be completed, notarized and submitted to the Board (30) days prior to
the scheduled date of the Board meeting at which they are to be reviewed.
In addition to the application, you must submit additional information directly to the Board. All items listed on the
“checklist” (page 9) must be submitted for an application to be considered complete. All applications are considered valid for 1 year from the day they are received at HEALTH. If you do not complete the application process and
obtain a license within 1 year a new application must be submitted.
Please allow a minimum of 4-8 weeks for the entire licensure process to be completed. If you have malpractice
criminal or disciplinary history, in Rhode Island or another state, it can take an additional 2 or 3 months for all
pertinent documentation to be received, and a decision to be made regarding issuance of your license.
Licenses will be issued within 7-10 working days following approval of the license. Wallet-sized license cards are
mailed within 3 weeks from the date of issuance, and are mailed to the address furnished in the application. You
are responsible for notifying the Board office, in writing, if your address changes in the interim. Visit the following
website to obtain a change of address form.
http://www.health.ri.gov/forms/changeofaddress/professions.pdf
To obtain your license number prior to receiving your license card, please refer to the HEALTH Licensee
Lookup web site:
https://healthri.mylicense.com/Verification/
HEALTH will not, for any reason, accelerate the processing of one applicant at the expense of others. Once
completed, the application will be reviewed, and you will be contacted in writing.
Please continue to review the remaining portions of this application packet for instructions and other materials
necessary to complete the application. If you have any questions about this application process, or would like to
check on the status of your application, please contact the board staff at (401) 222-2828.
Examination Information
The exam required for licensure is the National Clinical Mental Health Counselor Exam (NCMHCE). The
National Board of Certified Counselors (NBCC) is the national certification agency, which owns/administers
this exam. Upon receipt of your completed license application, HEALTH will register you with NBCC for the
next scheduled exam. You will receive notification of exam admittance, location, directions, etc. from NBCC
approximately ten (10) days prior to the exam date. NBCC sends exam results to HEALTH (not individual
applicants) in approximately six (6) weeks. HEALTH will then forward your exam results to you.
The exam is administered four times per year; dates may be found at our website:
http://www.health.ri.gov/hsr/professions/mf_counsel.php
For exam information, including the preparation guide and other study materials, please refer to the NBCC
website:
http://www.nbcc.org
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 3
INSTRUCTIONS FOR COMPLETING THE LICENSE APPLICATION
Read the following instructions and those throughout the application packet carefully before completing the application. Only
complete applications with the appropriate fee will be accepted. Failure to submit all required information and appropriate documentation may result in processing delays.
General Instructions
1. Make a copy of the application and forms before you begin in case you make a mistake.
2. Type your information or print in blue or black ball-point pen. HEALTH staff will not make assumptions about illegible
information.
3. Provide a response to each section or question; otherwise mark “N/A” for Not Applicable.
4. We suggest that you make a copy of your completed application before submitting it to HEALTH.
5. It is your responsibility to check on the status of your application.
Completing your Application
1. Complete the application (pages 5-8). You must respond to all components of the application as instructed. If you
attach separate pages in continuation of the application, such pages MUST clearly indicate the section for which such
information is being reported.
2. Make a check or money order (preferred), payable to the “Rhode Island General Treasurer” in the amount of
$460.00 and staple it to the upper left-hand corner of the first (Top) page of the application. NOTE: This application fee
is NON-REFUNDABLE . Please be advised that this is an application fee and includes the first license only up until the
next expiration date. All Mental Health Counselors licenses expire biennally on July 1st of the even numbered years.
3. For those born in US: An original or notarized copy of birth certificate. For those born outside US: An original or
notarized copy of citizenship or lawful alien status.
4. Two (2) original statements of good moral character from 2 unrelated people, dated no later than six (6) months previous.
Letters must be signed, dated and have a return address.
5. Affix a recent 2 X 2 photo of yourself in the space provided (page 8).
6. A completed official transcript sent directly from the accredited College or University to the Board of Mental Health
Counselors and Marriage & Family Therapists. No student copies will be accepted.
7. Scores of NCMHCE sent directly from the NBCC (Telephone 1-336-547-0607) to the Board of Mental Health
Counselors and Marriage & Family Therapists (pertains only to applicants who have previously sat for the national
exam).
8. Statement(s) of Supervised Practice (Original’s Only) (including supervisor’s resume) submitted to the Board of Mental
Health Counselors and Marriage & Family Therapists (page 10).
9. (Endorsement Candidates): Please send the license verification form on page12 to all states in which applicant
holds or has held a license. Be sure to sign and complete the identifying information on the form. The Board must
receive these verifications directly from the licensing authority in each state.
10. Mail the application and documentation to:
Rhode Island Department of Health
Board of Mental Health Counselors and
Marriage & Family Therapists, Room 104
3 Capitol Hill
Providence, RI 02908-5097
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 4
State of Rhode Island
Board of Mental Health Counselors and Family & Marriage Therapists
Application for License as a Mental Health Counselor
Refer to the Application Instructions when completing these forms. Type or block print only. Do not use felt-tip pens.
1. Name(s)
This is the name that
will be printed on your
License/Permit/
Certificate and
reported to those who
inquire about your
License/ Permit/
Certificate. Do not use
nicknames, etc.
Title (i.e., Mr., Mrs., Ms., etc.)
First Name
Middle Name
Surname, (Last Name)
Suffix (i.e., Jr., Sr., II, III)
Maiden, if applicable
Name(s) under which originally licensed in another state, if different from above (First, Middle, Last).
2. Social Security
Number
U.S. Social Security Number
3. Gender
Male
Female
19 9
1
4. Date of Birth
Month
5. Home
Address
It is your responsibility
to notify the board of all
address changes.
“Pursuant to Title 5, Chapter 76, of the Rhode Island General Laws,
as amended, I attest that I have filed all applicable tax returns and
paid all taxes owed to the State of Rhode Island, and I understand
that my Social Security Number (SSN) will be transmitted to the
Divison of Taxation to verify that no taxes are owed to the State.”
Day
Year
1st Line Address (Apartment/Suite/Room Number, etc.)
Second Line Address (Number and Street)
City
State
Country, If NOT U.S.
Postal Code, If NOT U.S.
Home Phone
Zip Code
Home Fax
Email Address (Format for email address is Username@domain e.g. applicant@isp.com)
6. Business
Address
(ONLY if it is
RELATED to
your license.)
Name of Business/Work Location
1st Line Address (Department/Suite/Room Number, etc.)
Second Line Address (Number and Street)
It is your responsibility
to notify the board of all
address changes.
City
This address will
appear on the
Department of
Health web site.
State
Postal Code, If NOT U.S.
Country, If NOT U.S.
Business Phone
Zip Code
Extension
Business Fax
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 5
Applicant: Print your complete last name >
7. Preferred
Mailing
Address
Please use my Home Address as my preferred mailing address
Please use my Business Address as my preferred mailing address
Please check ONE
8a. Qualifying
Education
Please list the name
and information about
the school that you
attended that
qualifies you for this
license.
Type of School (University, College, Technical School, etc.)
Name of School
Date Graduated:
Number of Credit Hours
Month
Year
Degree Received (Bachelor of Arts, Master of Science, Diploma, etc. )
8b. Supervised
Practicum,
Internship
and Work
Experience
Please list:
Supervised
Practicum
(12 semester or
18 quarter hours)
Supervised
Internship
(1 calendar year
of 20 hours/week)
Supervised
Work
Experience
(minimum 2000
hours PostGraduate
completed in
minimum of 2
years)
Approved
Supervisor of
Work
Experience
Include name and
address (minimum
100 hours)
9. Other State
License(s)
Please answer the
question and list
state(s), if applicable
10. Licensure
List all states or
countries in which
you are now, or
ever have been
licensed to practice
your profession.
Requirement
Location (Name and Address)
Date
Began
Date
Completed
Hours
Completed
Supervised
Practicum
(12 semester or 18
quarter hours)
Supervised
Internship
(1 calendar year of 20
hours/week)
Supervised
Work
Experience
(Minimum 2000 Hours
of Post- Graduate
Experience completed
in minimum of 2 yrs)
Approved
Supervisor
of Work
Experience
(Minimum of 100 Hrs.
Post-Graduate
Supervised Casework)
Have you ever held, or do you currently hold, a license in another state?
Yes
No
If the answer to this question is “yes”, enter all other state licenses in Question 10 (below):
State/Country:
State/Country:
Active
Inactive
Active
Inactive
Active
Inactive
Active
Inactive
Active
Inactive
Active
Inactive
Active
Inactive
Active
Inactive
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 6
Applicant: Print your complete last name >
11. Criminal
Convictions
Respond to the
question at the top
of the section, then
list any criminal
conviction(s) in the
space provided.
Have you ever been convicted of a violation, plead Nolo Contendere, or entered
a plea bargain to any federal, state or local statute, regulation, or ordinance or
are any formal charges pending?
Yes
No
Abbreviation of State and Conviction1 (e.g. CA - Illegal Possession of a Controlled Substance):
Month
Year
If necessary, you
may continue on a
separate 8½ x 11
sheet of paper.
12. Disciplinary
Questions
1. Has any Health Professional license, certificate, registration, or permit you
hold or have held, been disciplined or are formal charges pending?
Yes
No
2. Have you ever been denied a license, certificate, registration or permit in any
state?
Yes
No
Check either Yes or
No for each
question.
Note: If you answer “Yes” to any question, you are required to furnish complete details, including date, place, reason
and disposition of the matter. You may use the space below or, if needed, on a separate sheet of paper.
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 7
Applicant: Print your complete last name >
13. Affidavit of
Applicant
Complete this section
and sign in the
presence of a notary
public.
Make sure that you
and the notary public
have completed all
components
accurately and
completely.
I, ____________________________________, being first duly sworn, depose and say that I am the
person referred to in the foregoing application and supporting documents.
I have read carefully the questions in the foregoing application and have answered them completely, without
reservations of any kind, and I declare under penalty of perjury that my answers and all statements made by
me herein are true and correct. Should I furnish any false information in this application, I hereby agree that
such act shall constitute cause for denial, suspension or revocation of my license to practice as a Mental
Health Counselor in the State of Rhode Island.
I understand that this is a continuing application and that I have an affirmative duty to inform the Rhode
Island Board of Mental Health Counselors and Marriage & Family Therapists of any change in the answers
to these questions after this application and this affidavit is signed.
_____________________________________
_________________________________
Signature of Applicant
Date of Signature (MM/DD/YY)
The foregoing instrument was acknowledged before me this _____________ day of
___________________, 20_______, by ___________________________________,
who is personally known to me or has produced ____________________________
as documentation and did / did not take an oath.
_________________________________ _________________________________
Name of Notary (Print, Type or Stamp)
Signature of Notary
Notary Seal
________________________
__________________________
Notary No/Commission No.
Commission Expiration Date (MM/DD/YY)
14. Recent
Photograph
Securely tape or
glue in this square a
current 2" x 2"
photograph of
yourself (alone).
Photographs must be
recent, passport type
photo, clear, front
view, full face
without a hat or dark
glasses.
Affix Photo Here
Full length photos will
not be accepted.
Write your name on the back of the photograph, and provide the date that the photograph was taken.
Date of Photograph
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 8
APPLICATION CHECKLIST
Please review the following checklist to ensure that all the components of the application process have been satisfied. Some
items may not apply.
Board Application
I have read and understand the “Instructions for Completing the Application”.
I have completed the Rhode Island Board application as instructed (pages 5-8).
I have attached the cover page of the application.
I have completed Section 13, “Affidavit of Applicant”, and had the form notarized by a notary public.
I have attached a photograph to Section 14, “Recent Photograph” as instructed. I have verified that it meets the
photograph requirements as stated in the application.
I have attached a birth certificate (original or a copy notarized as being a true copy of the original), or if born
outside the United States, proof of citizenship or lawful alien status, (original or a copy notarized as being a true
copy of the original), and understand that submitted documents will not be returned.
I have made a check or money order (preferred), payable (in U.S. funds only) to the “Rhode Island General
Treasurer” in the amount of $460.00 (NON-REFUNDABLE) and attached it to the upper left-hand corner of the first
(Top) page of the application.
I have arranged my Board Application materials in the following order.
1.
Fee (attached as instructed).
2.
Board Application (including cover page) and pages 5-8.
3.
Core Curriculum Coursework Requirement Form (page 11)
4.
Supporting documentation as required. [Note: Pages containing additional information in continuation of the
Board application] MUST indicate the section for which the information is being reported.]
I have mailed the above application materials directly to the Rhode Island Board of Mental Health Counselors and
Marriage & Family Therapists.
Required Forms
I have completed and mailed the following forms as instructed.
1.
Statement of Supervised Practice Form (Original’s Only) (page 10) (With Supervisor’s Resume)
REQUIRED FOR ALL APPLICANTS
2.
Interstate Verification Form(s) - Other State License(s) (page 12) (Endorsement Candidates ONLY).
Other Documents
I have requested a school transcript and my certification score (NBCC), if applicable, as instructed.
Two (2) original statements of good moral character from 2 unrelated people, dated no later than six (6) months
previous. Letters must be signed, dated and have a return address.
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 9
Substitute forms are not acceptable, copy this form as needed.
RI Board of Mental Health Counselors and Marriage & Family Therapists
Room 104, 3 Capitol Hill
Providence, RI 02908-5097
(401) 222-2828
STATEMENT OF SUPERVISED PRACTICE
I am applying for a license to practice as a Mental Health Counselor in the State of Rhode Island. The Rhode Island Board of Mental Health Counselors and
Marriage & Family Therapists requires that the following section be completed by my supervisor. This constitutes authority for you to release all
information in your files, favorable or otherwise, directly to the Rhode Island Board at the above address.
Print/Type Full Name
Signature
Previous Names Used
Date
Date of Birth
19
THIS SECTION TO BE COMPLETED BY THE SUPERVISOR
1. What is the educational level of the supervisee?
2. Please provide the name and the nature of the setting in which the supervised practice took place.
3. Dates of practice covered in this report:
Number of practice hours during this period
4. Supervisee’s duties
Number of one-to-one supervisory hours
5. Assessment of supervisee’s performance (elaborate):
CERTIFICATION: I hereby acknowledge that the above statements are true and I am willing to accept professional
responsibility for the work done by the candidate while under my supervision. I will return this completed form directly to the Board
at the above address. I will also attach a copy of my curriculum vitae to this form for review by the Board.
Signature
Date
Printed Name
Title
Address
License Number
State in which granted
Area of specialization
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 10
Substitute forms are not acceptable, copy this form as needed.
RI Board of Mental Health Counselors and Marriage & Family Therapists
Room 104, 3 Capitol Hill
Providence, RI 02908-5097
(401) 222-2828
CORE CURRICULUM COURSEWORK REQUIREMENT FORM
Signature
Print/Type Full Name
Date
ALL APPLICANTS - PLEASE COMPLETE THE FOLLOWING:
In order to qualify for Licensure you must have taken graduate credit courses and graduate work in the
following areas. Please list your courses which correspond to the given content areas. Refer to the licensing
regulations (Appendix A-1) for clarification of the content areas. Elective courses that do not fit into the particular areas should be noted also. If the title of the course does not clearly reflect course content attach a
course description.
Content Area
Date
Course Code
Course Title
Credit Hours
1. Helping Relationships
and Counseling Theory
(9 credits minimum)
2. Human Growth and
Development
(3 credits minimum)
3. Social and Cultural
Foundations
(3 credits minimum)
4. Group Counseling
(3 credits minimum)
5. Lifestyle and Career
Development
(3 credits minimum)
6. Appraisal
(3 credits minimum)
7. Research and Program
Evaluation
(3 credits minimum)
8. Professional Orientation
(3 credits minimum)
9. Electives: (Courses
may reflect a specialization
area, or add knowledge &
skills in interdisciplinary
studies).
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 11
Substitute forms are not acceptable, copy this form as needed.
RI Board of Mental Health Counselors and Marriage & Family Therapists
Room 104, 3 Capitol Hill
Providence, RI 02908-5097
(401) 222-2828
INTERSTATE VERIFICATION FORM - OTHER STATE LICENSURE
I am applying for a license to practice as a Mental Health Counselor in the State of Rhode Island. The Rhode Island Board of Mental Health Counselors and
Marriage & Family Therapists requires that this form be completed by the jurisdiction(s) in which I hold or have held a license. This constitutes authority
for you to release all information in your files, favorable or otherwise, directly to the Rhode Island Board at the above address.
Print/Type Full Name
Signature
Date
Previous Names Used
Social Security Number
Date of Birth
19
License Number
Date Issued
THIS SECTION TO BE COMPLETED BY THE MENTAL HEALTH COUNSELORS BOARD
Counseling/Therapy Degree Completed:
Location:
Licensed by Examination?
Graduation Date:
Applicant has completed and passed the National Certification Exam (LCMHC):
Yes
No
Yes
No
Original Date Issued:
License Status:
Active
Inactive
Expiration Date:
Lapsed
Questions:
1. Has this licensee ever been investigated by your Board?
Yes
No
2. Has this licensee incurred any disciplinary proceedings in your state, or is any action pending?
Yes
No
3. Has the applicant’s license ever been denied, surrendered, reprimanded, suspended, revoked or placed
Yes
No
Yes
No
on probation?
4. Do you know of any information that may discredit this person?
If you answer “Yes” to questions 1-4, please provide a written explanation below, and attach a copy of all supporting documentation (e.g.,
Board order, complaint, etc.).
__________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________
Certification:
______________________________________________
Signature
___________________
Date
__________________________________________________________________________
Type or Print Name
Please Affix
Board Seal Here
__________________________________________________________________________
Title
__________________________________________________________________________
Full Name of Licensing Board
Please return directly to the Board at the above address. Thank you for your prompt cooperation.
Rhode Island Board of Mental Health Counselors and Marriage & Family Therapists - Page 12
