1. (a) Persons wishing to obtain licensure as a mental health practitioner in New Hampshire shall apply to the OPLC by completing and submitting the “Universal Application for Initial License”, and the “Addendum to the Universal Application for Initial License for Mental Health Practitioners” with the following information and documentation:

   1. (1) The information described in Plc 304.03 on the “Universal Application for Initial Licensure” form and signed and dated in accordance with Plc 304.05;

   2. (2) For clinical mental health counselors, the following information shall be provided on the “Addendum to the Universal Application for Initial License for Mental Health Practitioners”:

      1. a. 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 received a passing score?”; and
      2. b. 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. (3) For pastoral psychotherapists the following information shall be provided on the “Addendum to the Universal Application for Initial License for Mental Health Practitioners”:

      1. a. 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. (4) For licensed independent clinical social workers, the following information shall be provided on the “Addendum to the Universal Application for Initial License for Mental Health Practitioners”:

      1. a. Yes or no to the question “Have you previously taken the Association of State Social Worker Boards Clinical Examination?”; and
      2. b. Yes or no to the question “Was your graduate program in clinical social work approved by the Council on Social Work Education (CSWE)?”;
   5. (5) For school social workers, the same information provided on the “Addendum to the Universal Application for Initial License for Mental Health Practitioners” as required in (1) above;

   6. (6) For marriage and family therapist, the following information shall be provided on the “Addendum to the Universal Application for Initial License for Mental Health Practitioners”:

      1. a. 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
      2. b. 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. (7) For licensed social workers, the following information shall be provided on the “Addendum to the Universal Application for Initial License for Mental Health Practitioners”:

      1. a. Yes or no to the question “Have you previously taken the American Association of State Social Worker Boards Clinical or Bachelor Level Examination?”; and
      2. b. Yes or no to the question “Was your bachelor’s degree in social work approved by the Council on Social Work Education (CSWE)?”;

   8. (8) For social work associates, the following information shall be provided on the “Addendum to the Universal Application for Initial License for Mental Health Practitioners”:

      1. a. Yes or no to the question “Have you previously taken the Association of State Social Worker Boards Clinical or Bachelor Level Examination?”; and
      2. b. Yes or no to the question “Was your bachelor’s degree in clinical mental health, social work, psychology, behavioral health counseling, human services discipline, or equivalent program from an accredited college or university?”;
   9. (9) Supporting documents required of all applicants, as specified in Mhp 302.05(b);
   10. (10) The documents required for the criminal history records check required under RSA 330-A:15-a, II-IV;

   11. (11) The results of one of the following examinations required for the license the applicant is applying for:

       1. a. The New Hampshire Pastoral Psychotherapist Examination;
       2. b. The Association of State Social Work Boards, Clinical Level Exam;
       3. c. The National Clinical Mental Health Counselor Exam;
       4. d. The National Exam of the Association of Marriage and Family Regulatory Boards; or
       5. e. The Association of State Social Work Boards, Bachelor’s Level Exam;
   12. (12) The initial license fee as required by Plc 1002.29; and
   13. (13) Documentation of successful completion of the jurisprudence examination with a passing score described in Mhp 311.

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

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

      1. a. The “Summary of Supervised Clinical Experience Form – Clinical Mental Health Counselors, Licensed Independent Clinical Social Workers, Licensed Social Workers, Social Work Associates, Pastoral Psychotherapists, or School Social Workers” requiring the following information:

         1. 1. Applicant’s name;
         2. 2. The month and year for each start date and end date of each supervised clinical experience;
         3. 3. Name of facility for each supervised clinical experience;
         4. 4. Name of supervisor for each supervised clinical experience;
         5. 5. Total hours of each individual supervision received for each supervised clinical experience;
         6. 6. Total hours of clinical experiences for each supervised experience;
         7. 7. Total hours of supervised clinical experience for each experience; and

         8. 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

      2. b. The “Summary of Supervised Clinical Experience Form – Marriage and Family Therapist” requiring the following information:

         1. 1. Applicant’s name;
         2. 2. The month and year for each start date and end date of each supervised clinical experience;
         3. 3. Name of facility for each supervised clinical experience;
         4. 4. Name of supervisor for each supervised clinical experience;
         5. 5. Total hours of each individual supervision received for each supervised clinical experience;
         6. 6. Total hours of client contact for each supervised clinical experience;
         7. 7. Total hours of clinical experiences for each supervised experience;
         8. 8. Total hours of supervised clinical experience for all experiences; and

         9. 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. (2) One of the following supervisor’s confirmation of clinical experience forms:

      1. a. The “Supervisor’s Confirmation of Clinical Experience Form – Clinical Mental Health Counselors, Marriage and Family Therapists, Licensed Independent Clinical Social Workers, Licensed Social Workers, Social Work Associates, Pastoral Psychotherapists, or School Social Workers” requiring the following information:

         1. 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, marriage and family therapist, licensed independent clinical social worker, licensed social worker, social work associate, 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. 2. Name of the facility where the supervised clinical experience took place;
         3. 3. Address of the facility where the supervised clinical experience took place;
         4. 4. Applicant’s title at the time of supervision;
         5. 5. Beginning and ending month and year of supervised clinical experience;
         6. 6. Hours per week of face-to-face individual supervision;
         7. 7. Total hours of face-to-face supervision;
         8. 8. Total hours of paid supervised clinical work experience, which is the number of hours worked per week times the number of weeks worked;
         9. 9. A yes or no answer to the question “If the supervision took place in New Hampshire, was an approved “Candidate Licensure: Supervisor Agreement” on file with the OPLC prior to the commencement of supervision?”
         10. 10. Attach to this form a description of the supervisory methods and the types of issues dealt 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. 11. Printed name of supervisor(s);
         12. 12. Title of supervisor at the time of supervision;
         13. 13. Supervisor’s business address;
         14. 14. Highest degree earned by the supervisor;
         15. 15. The supervisor’s license type, state of licensure, license number, and date the license was issued;
         16. 16. Supervisor’s phone number; and
         17. 17. Supervisor’s signature and date of signing; or
   3. (3) Three separate and distinct “Professional Reference Form", each signed and submitted to the OPLC in a sealed enveloped so that it is evident it has not been tampered with by the person providing the reference, at least one of which is from a supervisor.

   4. (4) The “Professional Reference Form” which shall include the following information:

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

         1. 1. A check mark next to the type of application being applied for, licensed independent clinical social worker, licensed social worker, social work associate, school social worker, clinical mental health counselor, marriage and family therapist, or pastoral psychotherapist;
         2. 2. Their full legal name;
         3. 3. Their physical address including city, state, and zip code; and
         4. 4. Their signature and date of signing which authorizes the supervisor to release information to the OPLC and the NH Board of Mental Health; and

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

         1. 1. Their full legal name;
         2. 2. Their relationship with the applicant;
         3. 3. The length of time they have known the applicant;
         4. 4. A brief description of their knowledge of the applicant’s professional and ethical behavior;
         5. 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. 6. A brief description of the applicant’s duties and responsibilities at the organization;
         7. 7. The area of the applicant’s specialties;
         8. 8. A check mark as to whether the supervisor recommends the applicant for licensure with or without reservation, or if the supervisor does not recommend the applicant for license;
         9. 9. If the reference indicates with reservation or not recommended then provide a written explanation of that answer;
         10. 10. Their mailing address, phone number, title, degree, license or certification specialty, state(s) in which they are licensed, and license number(s); and
         11. 11. Signature and date of signing.

Source. (See Revision Note at chapter heading for Mhp 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 (formerly Mhp 301.03); ss by #13786, eff 12-19-23 (formerly Mhp 302.03); amd by #14052, EXRF, eff 8-17-24; ss by #14464, eff 2-17-26, EXPIRES 2-17-36