N.H. Code Admin. R. Mhp 302.05

Current through Register No. 17, April 25, 2024

Section Mhp 302.05 - Licensure Application Process

(a) Persons wishing to obtain licensure as a mental health practitioner in New Hampshire shall apply to the board by completing and submitting the following:

(1) The information described in Plc 304.03 on the "Universal Application for Initial Licensure" form and sign and date in accordance with Plc 304.05;

(2) For clinical mental health counselors, the following information shall be added to the information required in (1) above:

a. All names the applicant has ever been known by;

b. Yes or no to the question "Have you previously taken the National Clinical Mental Health Counselor Examination from the National Board for Certified Counselors (NBCC)?"; and

c. Yes or no to the question "Was your graduate program in clinical mental health counseling approved by the Council for Accreditation of Counseling or Related Educational programs (CACREP)?";

(3) For pastoral psychotherapists the following information shall be added to the information required in (1) above:

a. All names the applicant has ever been known by; and

b. Yes or no to the question "Have you previously taken the New Hampshire Pastoral Psychotherapist Association (NHPPA) Pastoral Psychotherapist Licensure Examination: Clinical Theory and Practice?";

(4) For independent clinical social workers, the following information shall be added to the information required in (1) above:

a. All names the applicant has ever been known by;

b. Yes or no to the question "Have you previously taken the American Association of State Social Worker Boards Clinical Examination?"; and

c. Yes or no to the question "Was your graduate program in clinical social work approved by the Council on Social Work Education (CSWE)?";

(5) For school social workers, the following information shall be added to the information required in (1) above:

a. All names the applicant has ever been known by;

b. Yes or no to the question "Have you previously taken the American Association of State Social Worker Boards Clinical Examination?"; and

c. Yes or no to the question "Was your graduate program in clinical social work approved by the Council on Social Work Education (CSWE)?";

(6) For marriage and family therapist, the following information shall be added to the information required in (1) above:

a. All names the applicant has ever been known by;

b. Yes or no to the question "Have you previously taken the Marriage and Family Therapist National Examination given by the Association for Marriage and Family Regulatory Boards?"; and

c. Yes or no to the question "Was your graduate program in marriage and family therapy approved by the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE)?";

(7) Supporting documents required of all applicant's, as specified in Mhp 302.05(b);

(8) The documents required for the criminal history records check required under RSA 330-A:15-a, II-IV, which include:

a. A criminal history record release form, also known as form DSSP from the department of safety, available at https://www.nhsp.dos.nh.gov/sites/g/files/ehbemt461/files/inline-documents/sonh/dssp2561_vgmedits.pd;

b. A completed fingerprint card or submission of Live Scan documentation. A fingerprint card may be obtained by contacting the board offices at (603) 271-2152. Livescan site locations are listed on the department of safety's website at https://www.certifixlivescan.com/category/fingerprinting-service-locations/new-hampshire/; and

c. A separate check made payable to "State of NH, Criminal Records" with the fee, as required by the department of safety;

(9) If the federal criminal history records check described in (8) above shows the existence of a criminal record in another state, the applicant shall obtain a detailed criminal record check directly from that state and provide it to the board;

(10) The results of one of the following examinations appropriate for the license the applicant is applying for:

a. The New Hampshire Pastoral Psychotherapist Examination;

b. The American Association of State Social Work Boards, Clinical Level Exam;

c. The National Clinical Mental Health Counselor Exam; or

d. The National Exam of the Association of Marriage and Family Regulatory Boards; and

(11) The initial license fee as required by Plc 1002.29.

(b) Each applicant for licensure shall submit with the application the following supporting documentation:

(1) One of the following supervised clinical experience forms:

a. The "Summary of Supervised Clinical Experience Form - Clinical Mental Health Counselors, Independent Clinical Social Workers, Pastoral Psychotherapist, or School Social Workers" requiring the following information:

1. Applicant's name;

2. Start and end date of each post-graduate supervised clinical experience;

3. Name of facility for each supervised clinical experience;

4. Name of supervisor for each supervised clinical experience;

5. Total hours of each individual supervision received for each supervised clinical experience;

6. Total hours of clinical experiences for each supervised experience;

7. Total hours of supervised clinical experience for all experiences; and

8. The applicant's signature and date of signing below the following attestation:

"By signing below, I certify that the foregoing is correct to the best of my knowledge."; or

b. The "Summary of Supervised Clinical Experience Form - Marriage and Family Therapist" requiring the following information:

1. Applicant's name;

2. Start and end date of each supervised clinical experience;

3. Name of facility for each supervised clinical experience;

4. Name of supervisor for each supervised clinical experience;

5. Total hours of each individual supervision received for each supervised clinical experience;

6. Total hours of client contact for each supervised clinical experience;

7. Total hours of clinical experiences for each supervised experience;

8. Total hours of supervised clinical experience for all experiences; and

9. The applicant's signature and date of signing below the following attestation:

"By signing below, I certify that the foregoing is correct to the best of my knowledge.";

(2) One of the following supervisor's confirmation of clinical experience forms:

a. The "Supervisor's Confirmation of Clinical Experience Form - Clinical Mental Health Counselors, Independent Clinical Social Workers, and Pastoral Psychotherapists, or School Social Workers" requiring the following information:

1. The applicant's name, address including city, state, and zip code, signature, and date of signing under the following statement:

"I am applying for licensure as a clinical mental health counselor, independent clinical social worker, pastoral psychotherapist, or school social worker in the State of New Hampshire. The Board of Mental Health Practice requires confirmation of supervised clinical experience. This is your authority to release all information you have in your files."

2. Name of facility where the post-masters supervised clinical experience took place;

3. Address of facility where the post-masters supervised clinical experience took place;

4. Applicant's title at the time of supervision;

5. Beginning and ending month and year of supervised clinical experience;

6. Hours per week of face-to-face individual supervision;

7. Total hours of face-to-face supervision;

8. Total hours of paid post-master's supervised clinical work experience, which is the number of hours worked per week times the number of weeks worked;

9. Answer yes or not to the question "If the supervision took place in New Hampshire was an approved "Candidate Licensure supervisor Agreement" on file in the board's office prior to the commencement of supervision?"

10. Attach to this form a description of the supervisor methods and the types of issues delt with during supervision, a description of the type of work performed by the applicant, and a description of the quality of work performed by the applicant completed by the supervisor;

11. Printed name of supervisor(s);

12. Title of supervisor at the time of supervision;

13. Supervisor's business address;

14. Highest degree earned by the supervisor;

15. What is the supervisor licensed as including the state of licensure, license number, and date the license was issued;

16. Supervisor's phone number; and

17. Supervisor's signature and date of signing; or

b. The "Supervisor's Confirmation of Clinical Experience Form - Marriage and Family Therapists" requiring the following information:

1. The applicant's name, address including city, state, and zip code, signature, and date of signing under the following statement:

"I am applying for licensure as a marriage and family therapist in the State of New Hampshire. The Board of Mental Health Practice requires confirmation of supervised clinical experience. This is your authority to release all information you have in your files."

2. Name of facility where the supervised clinical experience took place;

3. Address of facility where the supervised clinical experience took place;

4. Applicant's title at the time of supervision;

5. Beginning and ending month and year of supervised clinical experience;

6. For the total clinical experience the number of hours per week, the number of weeks, and total hours;

7. For the client contact hours the number of hours per week, the number of weeks, and the total number of hours;

8. The total hours of individual supervision;

9. The total number of hours of group supervision;

10. Answer yes or not to the question "If the supervision took place in New Hampshire, was an approved "Candidate Licensure supervisor Agreement" on file in the board's office prior to the commencement of supervision?"

11. Attach to this form a description of the supervisor methods and the types of issues delt with during supervision, a description of the type of work performed by the applicant, and a description of the quality of work performed by the applicant completed by the supervisor;

12. Printed name of supervisor(s);

13. Title of the supervisor(s) at the time of supervision;

14. Supervisor(s) address;

15. Highest degree earned by the supervisor(s);

16. What is the supervisor(s) licensed as including the state of licensure, license number, and date the license was issued;

17. Yes or no to the question "I am an AAMFT" approved supervisor and if no what other type of approval does the supervisor(s) have;

18. Supervisor(s) phone number; and

19. Supervisor(s) signature and date of signing; and

(3) Three separate and distinct "Professional Reference Forms", each signed by the person providing the reference, at least one of which is from a supervisor.

(4) The "Professional Reference Form" shall be provided by the board and require the following information:

a. The applicant for initial licensure shall complete the following information on the form before providing the form to the professional reference:

1. A check mark next to the type of application being applied for, independent clinical social worker, clinical mental health counselor, marriage and family therapist, or pastoral psychotherapist;

2. Their full legal name;

3. Their physical address including city, state, and zip code; and

4. Their signature and date of signing; and

b. After the applicant for licensure has completed the portion of the form described in a. above the applicant shall have the professional reference provide the following information on the form:

1. Their full legal name;

2. Their relationship with the applicant;

3. The length of time they have known the applicant;

4. A brief description of their knowledge of the applicant's professional and ethical behavior;

5. The name of the organization and the applicant's title and position at the organization when the professional reference worked with the applicant;

6. A brief description of the applicant's duties and responsibilities at the organization described in v. above;

7. The area of the applicant's specialties;

8. A brief description of any knowledge that the applicant:

a. Has been or is the subject of any malpractice or civil suit involving the practice of their profession;

b. Has been charged or convicted of a crime in any state or country, the disposition of which was other than acquittal or dismissal;

c. Has been or are any complaints or charges of violation of the ethical codes, professional misconduct, unprofessional conduct, incompetence, or negligence made or pending against them;

d. Has ever been required to surrender their license or certification; or

c. Has been found guilty of, or have entered into a consent decree regarding a violation of ethics codes, professional misconduct, unprofessional conduct, incompetence or negligence in any state or county by any licensing board or professional ethics body;

9. An attestation and certification that the reference believes that the applicant is an individual of good professional and moral character, and if the answer is no to provide an explanation;

10. A check mark next to the type of endorsement: without reservation, with reservation, or not recommended;

11. If the reference indicates with reservation or not recommended then provide a written explanation of that answer;

12. Their mailing address, phone number, title, degree, license or certification specialty, state(s) in which they are licensed, and license number(s); and

13. Signature and date of signing; and

c. The professional reference shall provide the "Professional Reference Form" to the applicant in a sealed envelope signed so it is evident it has not been tampered with.

(c) The application form and supporting documentation shall:

(1) Be legible;

(2) Have all sections complete or designated as not applicable to the applicant; and

(3) Be signed by the applicant.

(d) Any application 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; or

(3) The form is not signed where required by the applicant or other person who has completed that section.

(e) An application shall be considered completed and filed with the board as of the date the board has received:

(1) A fully completed application form;

(2) All required supporting documentation specified in Mhp 302.03; and

(3) Proof that the applicant's check has been deposited and cleared, if applicable.

(f) Upon receipt of a completed application, the board shall either:

(1) Within 30 days, request additional information or documentation; or

(2) Within 60 days of receipt of the completed application and any additional information requested pursuant to (1) above, approve or deny the application for licensure.

(g) The board shall deny an application if:

(1) The applicant has not passed the examinations as required by Mhp 302.5(a)(10);

(2) The educational attainment of the applicant does not meet the standards for the licensure being applied for as set forth in one of the following:

a.Mhp 303.01 for pastoral psychotherapists;

b.Mhp 304.01 for social workers;

c.Mhp 305.01 for mental health counselors; or

d.Mhp 306.01 for marriage and family therapists;

(3) The prelicensure supervised practice of the applicant does not meet the requirements for licensure being applied for as set forth in one of the following:

a.Mhp 303.02 for pastoral psychotherapists;

b.Mhp 304.02 for social workers;

c.Mhp 305.03 for mental health counselors; or

d.Mhp 306.02 for marriage and family therapists;

(4) The applicant does not meet the character qualifications of Mhp 302.02; or

(5) The applicant has not paid the fee required by Plc 1002.29.

(h) 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.

(i) 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.H. Code Admin. R. Mhp 302.05

(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 Number 45, Filed November 9, 2023, Proposed by #13786, Effective 12/19/2023, Expires 12/19/2033 (formerly Mhp 302.03).