1. (a) Students practicing under RSA 330-A:34, I(b) in a mental health discipline regulated by RSA 330-A shall complete and submit the following:

   1. (1) A “Candidate for Licensure: Supervision Agreement” described in Mhp 302.01(c), to the office of professional licensure and certification (OPLC) 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;
   2. (2) A “Universal Application for Initial License” required by Plc 304.03, the information and documentation required by Plc 304.04, and that is signed and dated in accordance with Plc 304.05; and
   3. (3) The applicable fee as set forth in Plc 1002.20.

2. (b) Upon receipt of the student’s completed “Candidate for Licensure: Supervision Agreement” the following shall apply until the student receives a license for supervised practice:

   1. (1) The student waiting for a supervision agreement shall be permitted to practice under the supervision of an individual licensed by the board and in good standing; and
   2. (2) The licensee supervising the student shall adhere to all requirements described in Mhp 302.03.

3. (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 by providing the following information:

   1. (1) The candidate for supervision shall complete part I of the “Candidate for Licensure: Supervision Agreement” by providing the following information:

      1. a. Indicate which of the following types of supervision the candidate is applying for:

         1. 1. Pastoral psychotherapist;
         2. 2. Licensed independent clinical social worker;
         3. 3. Clinical mental health counselor;
         4. 4. Marriage and family therapist;
         5. 5. School social worker;
         6. 6. Licensed social worker; or
         7. 7. Social work associate;
      2. b. The candidate’s full legal name;
      3. c. The candidate’s home physical address;
      4. d. The candidate’s home mailing address if different from the physical address;
      5. e. The candidate’s home or cell phone number;
      6. f. The candidate’s e-mail address;
      7. g. The candidate’s employer’s name;
      8. h. The candidate’s employer’s address;
      9. i. The candidate’s employer’s phone number;
      10. j. The candidate’s title at their place of employment;
      11. k. The supervisor’s name at the place of employment;
      12. l. A list of the college(s) or university(s) attended by the candidate, the date the degree was awarded or anticipated, and the actual or anticipated date(s) of graduation;

      13. m. A yes or no answer to the following questions, and if applicable, attach the requested document:

          “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;

      14. n. A yes or no answer to the question “Do you have a “Candidate for Licensure: Supervision Agreement” on file with the Board?”;
      15. o. A yes or no answer to the question “Are you changing supervisors?” If yes, attach a detailed explanation for the change in supervisors; and
      16. p. A yes or no answer to the question “Are you applying for conditional licensure?”;

   2. (2) The candidate’s supervisor shall complete part II of the “Candidate for Licensure - Supervision Agreement” and provide the following information:

      1. a. The supervisor’s full legal name;
      2. b. The supervisor’s employer’s name;
      3. c. The supervisor’s employer’s address;
      4. d. The employer’s phone number;
      5. e. The employer’s e-mail address;
      6. f. The supervisor’s title at place of employment;
      7. g. The physical address of where the supervision will take place;
      8. h. A yes or no answer to the question “Is the location where the supervision is to take place in an area that provides confidentiality?”;
      9. i. A yes or no answer to the question “Does the candidate have a W-2 work relationship with the employer?”;

      10. j. Check all that apply to “I hold a current, valid license in NH as:

          1. 1. Pastoral psychotherapist;
          2. 2. Licensed independent clinical social worker;
          3. 3. Clinical mental health counselor;
          4. 4. Marriage and family therapist;
          5. 5. School social worker; or
          6. 6. Licensed social worker”;
      11. k. A list of license numbers;
      12. l. A yes or no answer to the question “Have you been licensed in New Hampshire for more than 2 years?”;

      13. m. A yes or no answer to the following questions to ensure compliance with Mhp 302.03(a):

          1. 1. Did the supervisor complete a “graduate level course in clinical supervision?”;

          2. 2. Was the “clinical supervision approved by one of the following?

             1. (i) Association for Clinical Pastoral Education;
             2. (ii) National Association of Social Workers;
             3. (iii) American Mental Health Counselors Association; or
             4. (iv) American Association for Marriage and Family Therapy”; and
          3. 3. A yes or no answer to the question “Does the supervisor have 12 continuing education units (CEU’s) in clinical supervision through participation in a seminar or workshop approved by a Category A sponsor listed in Mhp 402.02(a)(1).”;
      14. n. Attach documentation proving the yes answer checked in response to m. above;
      15. o. A yes or no answer to the question “Are you an employee of your supervisee’s clinical site?”;

      16. p. If answered no to o. above, attach a detailed statement which addresses the following:

          1. 1. “Your relationship to the candidate’s employer or clinical site”;
          2. 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. 3. “That you have knowledge of candidate’s employer’s policies”; and
          4. 4. “How any disagreements between the contracted supervisor and the agency supervisor will be resolved”;
      17. q. Attach a dated and signed copy of the written agreement with the candidate’s employer that allows the review of records, files, and any other documentation at the supervisee’s place of employment or clinical site; and

      18. r. Certify the following statement by signing and dating the “Candidate for Licensure: Supervision Agreement”:

          “I affirm that I have reviewed the candidate’s education record, and it conforms with those outlined in Mhp 303, Mhp 304, Mhp 305, Mhp 306, Mhp 307, or Mhp 308 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. (3) The candidate and the supervisor shall complete part III of the “Candidate for Licensure: Supervision Agreement” by providing:

      1. a. An answer to the question “What is the length of individual supervision with one hour of supervision being 60 minutes?”;
      2. b. An answer to the question “What is the frequency of individual supervision?”; and

      3. c. A signed and dated description of the goals of supervision, that includes at least the following:

         1. 1. Ethics;
         2. 2. Diagnosis and assessment;
         3. 3. Theoretical applications;
         4. 4. Community resources;
         5. 5. Specific competence; and
         6. 6. Cross cultural issues; and

   4. (4) The candidate and the supervisor shall complete part IV of the “Candidate for Licensure: Supervision Agreement” as follows:

      1. a. The candidate for licensure shall certify by signing and dating the “Candidate for Licensure: Supervision Agreement” 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.”;

      2. 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 consistent, 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.”;

      3. c. In addition to b. above the supervisor of a marriage and family therapist shall certify by signing and dating the “Candidate for Licensure: Supervision Agreement” a second time under the following statement:

         “I acknowledge that, at a minimum, under RSA 330-A:22, I will hold, consistent 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 306.02(f), I will hold group face-to-face meetings with no more than six Candidates.”; and

      4. d. All candidates and supervisors shall sign and date the “Candidate for Licensure: Supervision Agreement”, in addition to any other signatures already affected to the “Candidate for Licensure: Supervision Agreement”, 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 “Candidate for Licensure: Supervision Agreement”.”

4. (d) In addition to any attachments required by (c) above the candidate for licensure shall arrange for an official transcript, which shows the relevant degree awarded or training received and the date the degree was awarded or training was completed, to be sent by the issuing institution electronically to the licensing bureau at customersupport@oplc.nh.gov or, if not possible to transmit electronically, by mailing the transcript to the OPLC licensing bureau at the address specified for the OPLC in Plc 103.03.

5. (e) The “Candidate for Licensure: Supervision Agreement” form shall:

   1. (1) Be legible;
   2. (2) Have all sections complete or designated as not applicable to the candidate; and
   3. (3) Be signed by the candidate and the candidate’s supervisor.
6. (f) Applications shall be reviewed as required by Plc 304.06 and Plc 304.08.
7. (g) If the “Candidate for Licensure: Supervision Agreement” is denied, the candidate shall be provided an opportunity to request a hearing for reconsideration pursuant to Plc 206.31 on the deficiency issues identified in the denial notification.
8. (h) In accordance with RSA 330-A:22, IV, the “Candidate for Licensure: Supervision Agreement” shall not be effective until it has been approved by the OPLC and no hours of supervised practice shall be credited to the candidate unless the agreement is effective.
9. (i) The supervisor and the candidate for licensure shall notify the OPLC, in writing, if any requirements contained in an approved “Candidate for Licensure: Supervision Agreement” cannot be met.
10. (j) Approval of a “Candidate for Licensure: Supervision Agreement” shall not guarantee licensure.

Source. (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; ss by #10857, eff 6-24-15; amd by #11076, eff 4-19-16; ss by #13786, eff 12-19-23 (see Revision Note at chapter heading for Mhp 300); amd by #14052, EXRF, eff 8-17-24; ss by #14464, eff 2-17-26, EXPIRES 2-17-36