The University of the State of New York

The State Education Department

Office of the Professions
Mental Health Counselor Form 5CS
Division of Professional Licensing Services Certification of Supervisor for Limited Permit
www.op.nysed.gov

Use this form ONLY if you are applying/have applied for a New York State Limited Permit as a Mental Health Counselor online.
Applicant Instructions
1. Complete Section I. Give your supervisor a copy of Appendix A and have them complete Section II. It is your responsibility to ensure your
supervisor fully completes Section II. Failure to complete this form will delay its review. Submit the completed certification to the Office of
the Professions as directed at the end of the form.
2. If you change supervisors or have additional settings or supervisors after a permit is issued, you must obtain an amended permit.
Complete the online Limited Permit Change Form application (https://eservices.nysed.gov/professions/wf/limited-permit-change) and
submit a Form 5CS for each new prospective supervisor. A new fee is not required for a permit issued as a result of a change in
supervisor or setting.
Section I: Applicant Information

1. Social Security Number 1 3 1 7 8 8 6 3 6 2. Birth Date Month 0 8 Day 2 0 Year 1 9 9 1

(Leave this blank if you do not have a U.S. Social Security Number)

3. Print Name Last S a m u e l

First J e n n i f e r

Middle Y a e l

4. I am applying for Original Permit ✔ Extension

Additional Setting Additional Supervisor
Change of Setting* Change of Supervisor*
*If you are applying for a change of setting or supervisor, please indicate the setting and/or supervisor being cancelled.

Section II: Supervisor's Certification

A limited permit may be issued to an applicant who has met all requirements for licensure except the licensing examination and/or experience
requirements. The permit is valid for two years, and may be extended, at the discretion of the Department, for up to two additional one-year
periods. The applicant may not be employed until the limited permit is issued.
Supervisor Instructions: Complete Section II to certify that the applicant will be supervised at the setting named below. You must also give
the applicant a copy of the operating certificate, corporate waiver certificate, authorization letter or certificate of incorporation if
required. This document authorizes the proposed setting to employ licensed professionals and provide services that are restricted
under Title VIII of the Education Law.

Supervisor's Name Marybeth Melendez

I am licensed and currently registered to practice in New York State as a: ✔ Mental Health Counselor Physician

Physician Assistant Registered Professional Nurse Licensed Clinical Social Worker Psychologist

Nurse Practitioner in (specialty)

New York State License number 010766 Date licensed 10 14 2020

mo. day yr.
08
Registration Expiration Date 31 2026
mo. day yr.
Employer (Employer and practice site must be located in New York State.):

Business Name MyTherapy.NYC

(Spell out/No abbreviation)

Business Address 374 Manor road

Street
Staten Island NY 10314
City State Zip Code
718-840-8280 [email protected]
Telephone Fax Email

Mental Health Counselor Form 5CS, Page 1 of 2, Rev. 2/22

Section II: Supervisor's Certification (continued)

Setting in New York State where supervised experience will take place (if different than employer):

Setting Name
(Spell out/No abbreviation)

Setting Address
Street

City State Zip Code

Telephone Fax Email

Check the type of setting where the supervised experience is to take place. Be sure to give a copy of the required document to the
applicant. This document MUST be included with the application. Failure to provide this information will delay the review of the limited permit
application. (Check one):
Office of Mental Health (OMH). Be sure to attach a copy of the Operating Certificate.
Office for People with Developmental Disabilities (OPWDD). Be sure to attach a copy of the Operating Certificate.
Office of Addiction Services and Supports (OASAS). Be sure to attach a copy of the Operating Certificate.
Department of Health (DOH). Be sure to attach a copy of the Operating Certificate.
Office of Children & Family Services (OCFS). Be sure to attach a copy of the Operating Certificate.
Department of Corrections and Community Supervision (DOCCS). Be sure to attach a copy of the Operating Certificate.
State Office for the Aging. Be sure to attach a copy of the Operating Certificate.

Not-for-profit, religious, or educational entity issued a corporate waiver by the New York State Education Department. Be sure
to attach a copy of the Corporate Waiver Certificate.
Psychotherapy Institute chartered by the New York State Education Department Board of Regents. Be sure to attach a copy of
the Corporate Waiver Certificate.
A program or facility authorized under Federal Law to provide services that are within the scope of practice of mental health
counseling. Be sure to attach a copy of the Authorization letter verifying the provision of professional services.
Public health agency or setting approved under the Mental Hygiene Law or a local social services district. Be sure to attach a
copy of the Authorization letter verifying the provision of professional services.
College and University Counseling Centers. Be sure to attach a copy of the Authorization letter verifying the provision of
professional counseling services to students.
Office of a licensed physician, clinical social worker, psychologist, or mental health counselor (PC, PLLC, PLLP) (not owned
by the applicant). Be sure to attach a copy of the Certificate of Incorporation.
Office of a professional licensed to practice mental health counseling as a sole proprietor not incorporated (not owned by the
applicant). No attachment required.

Attestation
I declare that the statements made in the foregoing certification are true, complete and correct. Any false or misleading information in or in
connection with this certification may be the cause for denial of permit and licensure and disciplinary action against my license and may result
in criminal prosecution.

Supervisor Signature Date

Print Name Marybeth Melendez

Address 374 Manor Road SI, NY, 10314

Telephone 718-840-8280 Fax Email [email protected]

Submitting this form

Upload this form in your online limited permit application. If you have already submitted your online limited permit application, upload this form
to: https://eservices.nysed.gov/professions/wf/document. You will need the Application ID of your limited permit submission that was emailed to
you and your date of birth. Or, you can mail this form along with any required documentation to: New York State Education Department, Office
of the Professions, Mental Health Counseling Unit, 89 Washington Avenue, Albany, NY 12234-1000

Mental Health Counselor Form 5CS, Page 2 of 2, Rev. 2/22

Appendix A, Requirements for Supervised Experience for Licensure as a Mental Health Counselor
The experience for licensure as a Mental Health Counselor requires completion of a supervised experience of at least 3,000 clock hours
providing Mental Health Counseling in a setting acceptable to the Department. The supervised experience must be obtained after completion
of the professional education requirement for licensure. All experience must be documented on Form 4B.

The supervised experience and practice under a limited permit must meet the following supervision and setting requirements.

Supervision of Experience

The supervisor must be licensed and registered in New York State as a Mental Health Counselor, physician, physician assistant, psychologist,
licensed clinical social worker, or registered professional nurse or nurse practitioner and competent in Mental Health Counseling in New York
State. An application in another jurisdiction must have the equivalent qualifications as determined by the Department.

An applicant must obtain experience for licensure while under the general supervision of a qualified supervisor. General supervision means
that a qualified supervisor is available for consultation, assessment and evaluation when professional services are being rendered by an
applicant and the supervisor exercises the degree of supervision appropriate to the circumstances.

The supervisor must provide at least one hour per week or four hours per month of in-person individual or group supervision where the
supervisor:
● reviews the applicant’s assessment, evaluation and treatment of each client under his or her general supervision; and
● provides oversight, guidance and direction to the applicant in developing skills as a Mental Health Counselor.

In addition, the supervisor is responsible for appropriate oversight of all services provided by a limited permit holder under his or her general
supervision. No supervisor can supervise more than five permit holders. The supervisor must not have a personal relationship with, or be
related to, the applicant.

Setting for Experience

An acceptable setting is defined in the Commissioner’s Regulations as:

i. a professional corporation, registered limited liability partnership, or professional service limited liability company authorized to provide
services that are within the scope of practice of Mental Health Counseling;
ii. a sole proprietorship owned by a licensee who provides services that are within the scope of his or her profession and services that
are within the scope of practice of Mental Health Counseling;
iii. a professional partnership owned by licensees who provide services that are within the scope of practice of Mental Health Counseling;
iv. a hospital or clinic authorized under Article 28 of the Public Health Law to provide services that are within the scope of practice of
Mental Health Counseling;
v. a program or facility authorized under the Mental Hygiene Law to provide services that are within the scope of practice of Mental
Health Counseling;
vi. a program or facility authorized under Federal Law to provide services that are within the scope of practice of Mental Health
Counseling;
vii. an entity defined as exempt from the licensing requirements or otherwise authorized under New York State law or the laws of the
jurisdiction in which the entity is located to provide services that are within the scope of practice of Mental Health Counseling.

The setting where the experience is gained is responsible for the services provided by the individuals gaining experience for licensure. The
setting is also responsible for providing adequate supervision to such individuals and for assigning a qualified supervisor, as defined in this
section, to individuals gaining experience for licensure.

The practice of Mental Health Counseling is defined in Education Law as:

● the evaluation, assessment, amelioration, treatment, modification, or adjustment to a disability, problem, or disorder of behavior,
character, development, emotion, personality or relationships by the use of verbal or behavioral methods with individuals, couples,
families or groups in private practice, group, or organized settings; and
● the use of assessment instruments and Mental Health Counseling and psychotherapy to identify, evaluate and treat dysfunctions and
disorders for purposes of providing appropriate Mental Health Counseling services.

Not less than 1,500 clock hours of such required experience, or one-half of the hours in any setting, shall consist of direct contact with clients
in the practice of Mental Health Counseling. The remaining experience may consist of other activities that do not involve direct client contact,
including but not limited to, recordkeeping, case management, research, supervision and professional development.

Mental Health Counselor Appendix A, Revised 7/19