Section Mhp 302.01 - Pre-Licensure Supervised Practice(a) Student interns or residents practicing per RSA 330-A:34, I(b) in a mental health discipline regulated by the board shall submit a completed "Candidate for Licensure: Supervision Agreement" described in Mhp 302.01(c), to the board at least 30 days prior to the end of the internship or residency if they wish to complete their supervised practice in the same location as their internship.(b) Upon the board's receipt of the student intern or resident's completed "Candidate for Licensure: Supervision Agreement" the following shall apply until the board issues a license for supervised practice:(1) The applicant waiting for a supervision agreement shall be permitted to practice under the supervision of an individual licensed by the board and in good standing;(2) The applicant waiting for a supervision agreement shall not work more than the 60 days allotted to obtain licensure; and(3) The licensee supervising the applicant shall adhere to all requirements described in Mhp 302.03.(c) Prior to beginning supervised practice as required by RSA 330-A:22, all candidates for licensed supervised practice and each supervisor shall complete and submit the "Candidate for Licensure: Supervision Agreement" form requiring the following: (1) The candidate for supervision to complete part I of the application as follows: a. Indicating which of the following types of supervision the candidate is applying for:1. Pastoral psychotherapist;2. Clinical social worker;3. Clinical mental health counselor; or4. Marriage and family therapist;b. The candidate's full legal name;c. The candidate's home physical address;d. The candidate's home mailing address if different from the physical address;e. The candidate's home or cell phone number;f. The candidates e-mail address;g. The candidate's employer's name;h. The candidate's employer's address;i. The candidate's employer's phone number;j. The candidate's title at their place of employment;k. Supervisor's name at the place of employment;l. List the college(s) or university(s) attended, the degree awarded, and date(s) of graduation;m. Answer yes or no to the following questions and if applicable attach the requested document: 1. "Have you ever been denied a certification or license you applied for?" If yes attach a detailed description including the denying board(s), date of denial(s), and reason for denial(s);2. "Have you ever been convicted of a felony or misdemeanor that has not been annulled?" If yes attach a detailed description of the offense(s) including the name of the court(s), date of conviction(s), and sentence(s) imposed; and3. "Do you suffer from any emotional disturbance, mental illness, organic illness, or addictive disorder which presently impairs your ability to serve as a mental health practitioner?" If yes attach a detailed description of how your ability to practice is impaired;n. Answer yes or no to the question "Do you have a "Candidate for Licensure: Supervision Agreement" on file with the Board?; ando. Answer yes or no the question "Are you changing supervisors?" If you answer yes attach a detailed explanation as to why you are changing supervisors;(2) The candidate's supervisor shall complete part II of the application as follows:a. The supervisor's full legal name;b. The supervisor's employer's name;c. The employer's address;d. Employer's phone number;e. Employer's e-mail address;f. Supervisor's title at place of employment;g. The physical address of where the supervision will take place;h. Answer yes or no to the question "Is the location where the supervision is to take place confidential?";i. Answer yes or no to the question "Does the candidate have a W-2 work relationship with the employer? (Independent contractor relationship not permitted)";j. Check all that apply to "I hold a current, valid license in NH as:i. Pastoral psychotherapist;ii. Clinical social worker;iii. Clinical mental health counselor; oriv. Marriage and family therapist";l. Answer yes or no to the question "Have you been licensed in New Hampshire for more than 2 years?"m. Answer yes or no to the following questions to ensure compliance with Mhp 302.01(c)(9): 1. Did the supervisor complete a "graduate level course in clinical supervision?";2. Was the "clinical supervision approved by one of the following?i. Association for clinical pastoral education;ii. National Association of Social Workers;iii. American Mental Health Counselors Association; oriv. American Association for Marriage and Family Therapy"; and3. "Does the supervisor have twelve continuing education units (CEU's) in clinical supervision through participation in a seminar or workshop was approved by a Category A sponsor listed in Mhp 402.02(a)(1).";n. Attach documentation proving the yes answer checked in response to n. above;o. Answer yes or no to the question "Are you an employee of your supervisee's clinical site?";p. If you answer no to p. above attach a detailed statement which addresses the following: 1. Your relationship to the candidate's employer or clinical site;2. Acknowledging that you will provide supervision at the candidate's place of employment or the clinical site where the applicant delivers services, at a mutually convenient and ethically appropriate site, or using a virtual HIPAA compliant platform;3. That you have knowledge of candidate's employer's policies; and4. How any disagreements between the contracted supervisor and the agency supervisor will be resolved; q. Attach a copy of the written agreement with the candidate's employer that allows you to review records, files, and any other documentation at the supervisee's place of employment or clinical site. This agreement shall be signed and bear the date of the signature; andr. Certify the following statement by signing and dating the application: "I affirm that I have reviewed the candidate's education record and it conforms with those outlined in Mhp 303, Mhp 304, Mhp 305, or Mhp 306, whichever refers to the appropriate candidate license type.
Additionally, I have read and shall conform to the laws of New Hampshire and the Board of Mental Health Practice Administrative Rules Mhp 100-500."
(3) Under part III of the application the following shall be completed: a. Answer the question "What is the frequency of individual supervision? (One hour of supervision is 60 minutes)";b. Answer the question "What is the length of individual supervision?";c. The candidate and supervisor shall complete and attach a description of the goals of supervision that include at least the following: 2. Diagnosis and assessment;3. Theoretical applications;5. Specific competence; and6. Cross cultural issues; and(4) Under part IV of the application the following shall be competed: a. A candidate for licensure under this agreement shall certify by signing and dating the application under the preprinted statement: "As a Candidate, I agree to provide my supervisor with all pertinent information concerning all clients and their care in order to make informed, ethical, and efficacious decisions for client care. I will inform my supervisor if I engage in any clinical activities outside of this agreement. I understand that all my clinical activity must be authorized by my supervisor. I will resolve all ethical dilemmas and practice issues as directed by my supervisor to the best of my ability. This supervision agreement does not remove any legal or civil responsibilities that I have for my actions related to this role.";
b. The supervisor shall certify by signing and dating the application under the following statement: "As the Supervisor, I agree to provide my Candidate with appropriate and efficacious training, guidance, and direction to assure a valuable training experience to meet standards for the Candidate's licensure. I acknowledge that, at a minimum, under RSA 330-A:22, I will hold weekly, one-hour face-to-face meetings at the site where the Candidate works, I will assume professional and legal responsibility for the Candidate, and I will review and have access to the Candidate's clinical records. If I cease to supervise the Candidate, if my license becomes invalid, restricted, or sanctioned in NH or any other jurisdiction, or if I wish to terminate my legal and professional responsibility for the Candidate's acts or omissions, I am responsible to notify the Board and the Candidate in writing, and that until I do, I remain responsible.";
c. In addition to b. above the supervisor of a marriage and family therapist shall certify by signing and dating the application a second time under the following statement: "I acknowledge that, at a minimum, under RSA 330-A:22, I will hold weekly, one-hour face-to-face meetings and that I will assume professional and legal responsibility for the Candidate. I will review and have access to the Candidate's clinical records. When providing outside Marriage and Family group supervision under Mhp 303.17 (e)(3), I will hold group face-to-face meetings with no more than six Candidates."; and
d. All candidates and supervisors shall sign and date the application, in addition to any other signatures already affected to the application, certifying the following statement: "All statements and information contained in this form are true and correct to the best of my knowledge and belief. I acknowledge that the provision of false information on this form is a basis for denial of this application."
(d) In addition to any attachments required by (c) above the candidate for licensure shall submit with the first "Candidate for Licensure: Supervision Agreement" their graduate transcripts in an envelope sealed and signed by the issuing school.(e) The "Candidate for Licensure: Supervision Agreement" form shall:(2) Have all sections complete or designated as not applicable to the applicant; and(3) Be signed by the applicant and the applicant's supervisor.(f) Each "Candidate for Licensure: Supervision Agreement" shall be accompanied by: (1) The applicable fee as set forth in Plc 1002.29; and(2) A copy of the candidates transcripts described in Mhp 303 through Mhp 306.(g) Any "Candidate for Licensure: Supervision Agreement" form shall be returned to the applicant as incomplete if:(1) Any portion of the form is illegible; (2) Any section of the form is incomplete;(3) The form is not signed where required by the applicant or supervisor who has completed that section; or(4) It is not accompanied by the documents described in Mhp 302.01(f).(h) A "Candidate for Licensure: Supervision Agreement" shall be considered filed with the board as of the date the board has received:(1) A fully completed application form;(2) An official graduate school transcript in a signed, sealed envelope; and(3) The candidate agreement review fee described in Plc 1002.29.(i) Within 30 days of the date the "Candidate for Licensure: Supervision Agreement" is on file with the board, the board shall request the applicant to provide additional information or documentation determined to be needed to clarify the application or any materials related to the application.(j) The board shall approve or deny the proposed "Candidate for Licensure: Supervision Agreement" within 60 days of receipt of the application and all supporting documents.(k) The "Candidate for Licensure: Supervision Agreement" shall be denied if: (1) The supervisor does not meet the requirements set forth in Mhp 302.01(c);(2) The candidate does not meet the educational requirements of:a.Mhp 303.01 for pastoral psychotherapists;b.Mhp 304.01 for independent clinical social workers;c.Mhp 305.01 and Mhp 305.02 for clinical mental health counselors; ord.Mhp 306.01 for marriage and family therapists; or(3) The candidate is a 1099 employee of an independent private practice.(l) If the application is denied, the applicant shall be provided an opportunity to request a hearing for reconsideration pursuant to Mhp 208.16 on the deficiency issues identified by the board.(m) Any such request for a hearing shall be submitted to the board within 30 days from the date of the board's notification of denial or return from active military duty, failing which the denial shall be deemed final.(n) Pursuant to RSA 330-A:22, IV, no hours of supervised practice shall be credited to the candidate until the "Candidate for Licensure: Supervision Agreement" has been approved by the board.(o) The supervisor and the candidate for licensure shall notify the board, in writing, if any requirements contained in an approved "Candidate for Licensure: Supervision Agreement" cannot be met, and may request the board:(1) To approve a new supervisor for the candidate, which shall be granted so long as the new proposed supervisor qualifies under the provision of this rule;(2) To terminate the agreement, which shall require the candidate to reinstitute the process of pre-licensure supervised practice from the beginning; or(3) Otherwise change a provision of the "Candidate for Licensure: Supervision Agreement", which shall be granted so long as no proposed change results in a violation of RSA 330-A:22.(p) A request to terminate or modify an approved "Candidate for Licensure: Supervision Agreement" shall be approved or denied within a reasonable time, not to exceed 60 days from the date the request has been filed with the board. If denied, the candidate may seek reconsideration or appeal as in (l) and (m) above.(q) Approval of a "Candidate for Licensure: Supervision Agreement" shall not guarantee licensure.N.H. Code Admin. R. Mhp 302.01
(See Revision Note at chapter heading for Psy 100) #5675, eff 7-22-93; EXPIRED: 7-22-99
New. #7625, eff 1-10-02, EXPIRED: 1-10-10
New. #9854, eff 1-25-11
Amended by Volume XXXV Number 27, Filed July 9, 2015, Proposed by #10857, Effective 6/24/2015, Expires6/24/2025.Amended by Volume XXXVI Number 19, Filed May 12, 2016, Proposed by #11076, Effective 4/19/2016, Expires 4/19/2026.Amended by Number 45, Filed November 9, 2023, Proposed by #13786, Effective 12/19/2023, Expires 12/19/2033 (see Revision Note at chapter heading for Mhp 300).