Current through Register No. 12, March 21, 2024
(a)
Prior to beginning supervised practice as required by
RSA
330-A:22, all candidates for licensure as a
mental health practitioner and each supervisor shall complete, sign and submit
the "Candidate for Licensure: Supervision Agreement" form dated
6/19/15.
(b) The candidate shall
supply the following:
(1) Name;
(2) Home address;
(3) Email address;
(4) Name of employer;
(5) Employer address;
(6) Place of employment;
(7) Title at place of employment;
(8) Supervisor's name at place of
employment;
(9) Telephone number at
home and place of employment;
(10)
Name of undergraduate school, type of degree granted, and date of
degree;
(11) Name of graduate
school, and official transcript certified by a school official showing all
coursework, type of degree granted, and date of degree;
(12) A complete explanation of any "Yes"
response to the following 5 questions as set forth on the "Candidate for
Licensure: Supervision Agreement" form dated 6/19/2015:
a. "Have you ever had a malpractice claim
against you within the previous 6 years, regardless of whether a lawsuit was
filed in relation to the claim?;"
b. "Do you have any complaints pending
against a license or certificate in any state or jurisdiction, and if so, the
details of the complaint?;"
c.
"Have you ever been denied a certificate or license you applied for, and if so,
the name of the denying board, the date of the denial, and the reasons for
denial?;"
d. "As required by
RSA
651:5 X, have you ever been convicted of a
felony or misdemeanor (that has not been annulled)? If so please state the name
of the court, the details of the offense, the date of the conviction, and the
sentence imposed.;" and
e. "Have
you ever had, or currently have an emotional disturbance or mental illness, an
organic illness, or addictive disorder which impaired your ability to practice
mental health counseling, and if so, the treatment received and the outcome of
such treatment?"
(13)
Certification that:
a. All pertinent
information concerning all clients and their care in order to make informed,
ethical and efficacious decisions for client care;
b. All clinical activity is authorized by my
supervisor;
c. All ethical dilemmas
and practice issues will be resolved as directed by my Supervisor to the best
of my ability;
d. The candidate for
licensure: supervision agreement does not remove any legal or civil
responsibilities that I have for my actions related to this role;
e. All of the above statements, and all
statements and information contained in this form are true and correct to the
best of my knowledge and belief; and
f. Acknowledgement that the provision of
false information on this form is a basis for denial of this
application.
(14) A
written statement as to why there is a change in supervisor if the candidate
already has an approved "Candidate for Licensure: Supervision Agreement" on
file with the board.
(c)
Supervisors of candidates shall supply the following information:
(1) Name;
(2) Business name and address;
(3) Business telephone number;
(4) Business email address;
(5) Title at place of employment;
(6) A certification that the supervisor has
been licensed to practice mental health by the board or by the licensing board
in another jurisdiction for a minimum of 2 years prior to the date supervision
with the candidate is to commence,; or, for marriage and family therapists as
allowed by Mhp
306.02(a);
(7) A certification that the supervisor holds
a mental health practitioner license that is current, in good standing and does
not have any restrictions;
(8) A
certification that the supervisor is licensed in the same profession for which
the candidate seeks licensure;
(9)
A certification that the supervisor has successfully completed one of the
following:
a. A graduate level course in
clinical supervision;
b. A clinical
supervision certificate approved by one of the following:
1. American Association of Pastoral
Counselors;
2. National Association
of Social Workers;
3. American
Mental Health Counselors Association; or
4. American Association for Marriage and
Family Therapy; or
c.
Twelve continuing educations units (CEU's) in clinical supervision prior to
entering the supervision relationship meeting the requirement set forth in
Mhp
402.02(a)(1);
(10) A response of "yes" or "no" to the
question: "are you an employee of your supervisee's clinical site?
(11) If the answer is "no" to the question in
(10) attach a written statement to the Candidate for Licensure: Supervision
Agreement which addresses the following:
a.
Your relationship to the candidate's employer/clinical site;
b. A statement acknowledging you will provide
supervision at the candidate's place of employment/clinical site;
c. A copy of a written agreement with the
candidate's employer that allows you to review records, files etc. at the
supervisee's place of employment/clinical site;
d. A statement that you have knowledge of a
candidate's employer's policies; and
e. How any disagreements between the
contracted supervisor and the agency supervisor will be resolved.
(d) The candidate and
supervisor shall jointly supply the following information:
(1) The proposed starting date of
supervision;
(2) The proposed
completion date of supervision;
(3)
The frequency of individual face to face supervision;
(4) The length of face to face supervision
expressed in 60 minute hours; and
(5) A statement describing the goals of the
supervised practice in the areas of:
a. Ethics
specific to the profession;
b.
Diagnosis and assessment of mental health issues;
c. Theoretical applications of treatment
methods;
d. Community resources
available to the patient;
e.
Specific competence of the candidate to effect treatment; and
f. Cross cultural issues.
(e) Each "Candidate for
Licensure: Supervision Agreement" shall be accompanied by the applicable fee as
set forth in Mhp
307.01(f).
(f) The "Candidate for Licensure: Supervision
Agreement" form shall:
(1) Be typewritten or
legibly printed;
(2) Have all
subsections complete or designated as not applicable to the applicant;
and
(3) Be signed by the
applicant.
(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; or
(3) The form is not signed where required by
the applicant or other person who has completed that section.
(h) A "Candidate for Licensure:
Supervision Agreement" shall be considered to be on file 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) Proof that the applicant's check has been
deposited and cleared, if applicable.
(i) Within 60 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 a reasonable time, not to exceed 120 days from:
(1) The date the application is on file with
the board; or
(2) The date of the
response to a request pursuant to
Mhp
302.01(i).
(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) (6-10);
(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;
or
d.
Mhp
306.01 for marriage and family therapists;
or
(3) The supervised
practice takes place in a private practice setting.
(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, 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 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 (k) and (l) above.
(q) Approval of a "Candidate for Licensure:
Supervision Agreement shall not guarantee licensure.
(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
