Mental Health Counselor Form 4B - New York State …

The University of the State of New York The State Education Department Office of the Professions Division of Professional Licensing Services Mental Health Counseling Form 4B Certification of Supervised ExperienceApplicant InstructionsAssigned Number (from Form 4) Section I. Be sure to sign and date item the entire form and a copy of Appendix A to the supervisor who will certify your experience to complete Section II and forward all pages of this form directly to the Office of the Professions at the address at the end of this form. This form will not be accepted if submitted by the I: Applicant 4 Digits of Social Security Number(Leave this blank if you do not have a Social Security Number) DateMonth NameLastFirstMiddleLicensee business address, phone and email address are public information. Failure to indicate business or home on this form for each item will deem it public Address Home orBusiness (You must notify the Department within 30 days of any address or name changes)Line 1 Line 2 Line 3 CityStateZIP CodeCountry/ AddressDaytime PhoneHome orBusinessArea CodePhoneEmail Address (please print clearly)Home York State DMV ID Number (Driver or Non-Driver ID)(Leave this blank if you do not have a New York State DMV ID Number) as it appears on degree or other credentials (if di)

Elementary, middle, high school or college authorized to provide psychotherapy services to students (attach copy of authorization) Not-for-profit or other entity authorized by waiver from the State Education Department to employ licensed professionals and provide services

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  Health, High, School, Counselor, Mental, Middle, Elementary, High school, Mental health counselor

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