NYSED Form 4B for the LMHC and LMFT: who fills it in and who sends it

At a glance

The LMHC’s Form 4B

For the license in mental health counseling (Education Law §8402; 8 NYCRR 79-9.3). Section I asks for your “Total clock hours practicing Mental Health Counseling” in that supervised experience. The license needs at least 3,000 clock hours, of which at least 1,500 are direct contact with clients, or half the hours in any setting. The rest can be recordkeeping, case management, research, supervision and professional development (Appendix A).

• Your supervisor attests that they supervised you “at least one hour per week or two hours every other week”. The regulation calls this an average, face to face, individual or group, and face to face may be by secure video (79-9.3). Appendix A (Revised 7/19) and NYSED’s requirements page still say in person (Appendix A: “four hours per month”). Neither the form nor the regulation asks for a total of supervision hours
• Who can certify it: a supervisor licensed and registered in New York 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 (Appendix A)
• How it is sent: “Submit this form by email to DPLSExperience@nysed.gov, or, by mailing” it to NYSED, Office of the Professions, Division of Professional Licensing Services, Mental Health Counseling Unit, 89 Washington Avenue, Albany, NY 12234-1000 (Form 4B, page 2)
• Appendix A, Requirements for Supervised Experience for Licensure as a Mental Health Counselor, goes to the supervisor with the form. In Section II the supervisor certifies having read it

How to become an LMHC in New York

The LMFT’s Form 4B

For the license in marriage and family therapy (Education Law §8403; 8 NYCRR 79-10.3). Section I asks for your “Total client contact hours practicing Marriage and Family Therapy”. The license needs at least 1,500 client contact hours, and all of them are direct contact with clients (79-10.3(a); Appendix A). Client contact hours from a licensure-qualifying marriage and family therapy degree program can count; with a degree in an allied field, the experience comes after that degree. Either way, “All experience must be documented on Form 4B” (Appendix A, Revised 2/19).

• Your supervisor attests that they supervised you “at least one hour per week or two hours every other week”. The regulation calls this an average, face to face, individual or group, and face to face may be by secure video (79-10.3). Appendix A and NYSED’s requirements page still say in person (Appendix A: “four hours per month”). Neither the form nor the regulation asks for a total of supervision hours
• Who can certify it: a supervisor licensed and registered in New York as a marriage and family therapist, physician, physician assistant, psychologist, licensed clinical social worker, or registered professional nurse or nurse practitioner, and competent in marriage and family therapy (Appendix A). A licensed mental health counselor is not on the list
• Appendix A, Requirements for Supervised Experience for Licensure as a Marriage and Family Therapist, goes to the supervisor with the form. In Section II the supervisor certifies having read it

How to become an LMFT in New York

Can an LMFT’s supervisor email Form 4B?

NYSED hasn’t settled it. The form itself ends “Return Directly to:” NYSED, Office of the Professions, Division of Professional Licensing Services, Marriage and Family Therapy Unit, 89 Washington Avenue, Albany, NY 12234-1000, and its item 9 asks the supervisor to mail it; it gives no email address.

NYSED’s LMFT forms page, under Electronic Verification of Experience, says the Office of the Professions accepts experience forms directly from supervisors when it can verify they came from the supervisor and the applicant couldn’t alter them, and that “Any experience documentation submissions should be made electronically to DPLSExperience@nysed.gov.” It doesn’t say whether that covers the LMFT’s Form 4B.

Mail follows the form. If your supervisor would rather email it, ask NYSED first (opunit5@nysed.gov).

Who completes which part?

• You, Section I: the last four digits of your Social Security number, birth date, name, mailing address, phone and email, New York DMV ID if you have one, your supervisor’s name, the dates the supervised experience began and ended, and its total hours. Write the number this experience has on your Form 4 at the top (“Assigned Number (from Form 4)”)
• Sign and date item 9: it asks the supervisor to complete Section II and send it, and affirms that what you wrote is true
• Your supervisor, Section II: their professional title, where they are licensed, license number and date licensed; the dates of your experience and your total hours practicing the profession (each form names its own: mental health counseling or marriage and family therapy), not a total of supervision hours; the setting, its type and address; the attestation, signed and dated
• Section II also has a line for an agency representative’s signature, under the form’s statement that the supervisor must be employed by the same agency as you, has access to all patient files and records, and is responsible for each patient you treat, and that each patient consents to treatment by you. The form doesn’t say who the representative is

What does the supervisor attach?

The form asks the supervisor to “attach the operating certificate, NYSED waiver or certificate of incorporation” that authorizes the setting to employ the profession, and lists what each type of setting attaches:

• A program approved by OMH, OPWDD, OASAS, OCFS, DOCCS, DOH, the State Office for the Aging, or a local social service or mental hygiene district: its operating certificate
• A not-for-profit or other entity authorized by a NYSED waiver: the waiver and its certificate of incorporation
• A professional entity (PLLC, PLLP, P.C.) owned by a qualified supervisor: NYSED’s consent
• A sole proprietorship or other entity authorized under law: the form’s “certificate of corporation”
• A psychotherapy institute chartered by the Board of Regents: its Regents charter
• A school or college authorized to provide psychotherapy services to students: its authorization
• A private practice owned by the supervisor: the form names no attachment
• Experience outside New York: “a copy of your license and an operating certificate or authorization for the entity to provide professional services”

Signed and dated by hand

You sign and date item 9, and your supervisor signs and dates the attestation. Neither form, nor any NYSED page, says an electronic signature (typed, drawn or through a signing service) is accepted, so sign by hand. A form that is emailed is a scan of the signed pages, sent by the supervisor.

One Form 4B for each supervised experience

• NYSED: “A separate Form 4B must be submitted for each supervised experience you list on the Applicant Experience Record (Form 4).” Two supervisors mean two forms. Form 4 lists each supervisor and setting on its own line, so one supervisor at two settings is likely two forms; ask NYSED if unsure
• For experience in New York, “The supervisor must be the supervisor named on your limited permit” (both professions’ forms pages)
• You send Form 4 yourself: upload it to your online application at eservices.nysed.gov/professions/wf/document, or email it to DPLSExperience@nysed.gov, or mail it (Form 4, Rev. 7/26)
• NYSED’s requirements pages: “It is your responsibility to follow up with anyone you have asked to send us material”

What if my supervisor has died or can’t sign?

Form 4, item 8 (the same words on the LMHC’s and the LMFT’s, Rev. 7/26): “If a supervisor is deceased, you should list a licensed colleague who will attest to your supervised experience and to the qualifications of the deceased supervisor.” Where the supervisor’s own attestation isn’t available, both requirements pages say NYSED “may accept an attestation of the duration and frequency of the supervised experience and the qualifications of the supervisor submitted by a licensed colleague.”

Form 4B has no part for a colleague, and NYSED doesn’t say which form the colleague completes or how they send it. Ask NYSED (opunit5@nysed.gov) before your colleague fills anything in.

What about experience outside New York?

Both regulations say experience in another jurisdiction “may be accepted” if it was in a setting authorized there and under a qualified supervisor (LMHC: 79-9.3(b)(2); LMFT: 79-10.3(a)(2)). NYSED decides. The experience must have been legal where it happened, and a supervisor elsewhere needs the equivalent qualifications, as NYSED determines (requirements pages; Appendix A).

That supervisor completes the same Form 4B for your license, and must include a copy of their license and an operating certificate or authorization for the entity.

Is this the LCSW’s Form 4B?

No. Social workers file the LCSW’s own Form 4B, a different form with its own rules.

NYSED Form 4B for the LCSW

Form 4D, for the diagnostic privilege

Form 4D is a different form, shared by LMHCs and LMFTs. It certifies experience for the diagnostic privilege, which you apply for once licensed, and the person certifying it sends it to NYSED.

NY diagnostic privilege forms 1D, 2D, 4D and 5D, and checking your status