Retroactive Certification Application

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Complete a separate entry for each separate activity. CE Activity submissions will not be processed if forms are not completed correctly.

Applicant Information

Name *

E-mail *

LMHC License # *

License Renewal Cycle *

Street Address *

City *

State *

Zip code *

Telephone *

Work setting *

Continuing Education Activity - Title *

Sponsoring Organization Information

Name *

Street Address *

City *

State *

Zip code *

Instructor Name and License type *

Qualification of Instructor/s to teach MHC material (check at least one) *

Licensed MHC (in any State)

Other licensed mental health professional

Approved Supervisor as defined by 262 CMR 2.00

Masters level staff member of an agency providing MHC services, minimum 2 years MHC experience.

Masters level Faculty member in an educational institution educating LMHCs.

Other

Explain other qualifications *

Schedule:

Fill in the exact schedule below with the total instructional hours excluding registration, lunch and coffee breaks. If the schedule is repeated more than one day, indicate the dates to the left. When a provider does not indicate a break in a four-hour period 15 minutes will be deducted from the time for a break period. When the provider does not indicate a lunch break in a workshop over 6 hours, one hour will be deducted for a lunch break. When the provider does not indicate a lunch break or other small breaks in a workshop 8 hours or more, a one hour lunch break and two 15 minute smaller breaks will be deducted from the original hours requested.

Date *

Session Start *

Session End *

Number of instructional hours *

Date

Session Start *

Session End *

Number of instructional hours *

Date

Session Start *

Session End *

Number of instructional hours *

Verification of Attendance (Include a copy with this application, RETAIN ORIGINALS.)
a. Continuing Education certificate or letter of attendance from another mental health profession; OR
b. Other means of official verification of attendance that includes title, number of hours, instructor and content. *

Does the activity description clearly indicate relevance to mental health practice? *

Yes

No

Attach of PDF of the workshop brochure or a PDF copy of the webpage *

By typing my name below, I attest all of the above statements are correct and have been personally verified by me to the extent possible. *

Fees: $25.00 for each application. $50.00 if submitted after October 15, of a renewal year (odd years) *

Between Jan 1 of even year and October 15 of odd year ($25.00)

After October 15 of odd year ($50.00)

Current Total:

$0.00