MaMHCA Certified Clinical Supervisor MCCS Application

Please complete the following form to submit your application for the MaMHCA MCCS credential.

Your listing will be accessible by all visitors to the MaMHCA website.

Fields with an asterisk (*) are required.

Name *

Address *

City *

State *

Zip Code *

Best Phone Number *

Email address *

License type and number [i.e. LMHC # 123456] *

Please upload a copy of your License here *

Are you a MaMHCA member? [not required for MCCS credentials] *

Yes

Name of Professional Liability Carrier: *

Please upload a copy of your cover sheet or coverage confirmation details here *

Documentation of Workshop Completion

S1 Frameworks for Supervision Date Completed *

S1 Frameworks for Supervision CEU Certificate uploaded *

S2 Legal Ethical and Regulatory Issues in Supervision Date Completed *

S2 Legal Ethical and Regulatory Issues in Supervision CEU Certificate uploaded *

S3 Recordkeeping in Supervision Date Completed *

S3 Recordkeeping in Supervision CEU Certificate uploaded *

Please list one or two areas of specialty here:

MASSACHUSETTS REGULATIONS ATTESTATION: I attest under the pains and penalties of perjury that I have downloaded, read and reviewed the Massachusetts 262 CMR Section 2.02 and Section 8 pertaining to LMHC licensure and Standards of Practice. [Please sign below by typing your name in the box]

*

ETHICS ATTESTATION: I agree to abide by the Massachusetts 262 CMR Section 8 Code of Ethics and Standards of Practice as a clinician and a supervisor. [Please sign below by typing your name in the box] *

I request a frameable certificate. Please type your name as you wish it to appear on your certificate. NOTE: 100% of the fee for your certificate is applied to the MaMHCA-Haberman-Williams Scholarship and License Application Grant Fund devoted to assisting new professionals meet their educational license process fees.

MCCS Certificate ($35.00)

Fields with an asterisk (*) are required.

First Name *

Last Name *

Email Address *

Cell Phone Number *