Get Mental Health Counselor Associate Supervision And Experience Verification Doh 670-128. This Form

Filling out the Mental Health Counselor Associate Supervision And Experience Verification DOH 670-128 form is an essential step in verifying your supervised experience as a mental health counselor. This guide will walk you through each section and field, ensuring you complete the form accurately and efficiently online.

Follow the steps to complete the form accurately

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section 1, print or type your information clearly in the required fields including your last name, first name, middle name, birth date, and address.
3. In Section 2, provide your approved supervisor's information. This includes their name, current phone number, credential state, first issuance date, and street address.
4. In Section 3, indicate the timeframe of your supervised experience by filling in the dates from when you were supervised to when your supervision ended.
5. Complete the hours of supervised postgraduate experience. Enter the number of hours in immediate supervision, direct counseling, and any other supervised hours, totaling the hours to confirm you meet the 3,000 hours requirement.
6. As the supervisor, they must certify the accuracy of the information by signing and dating the form.
7. Once all sections are completed, save your changes, and you can choose to download, print, or share the form as needed.

Ensure you complete the necessary documentation online to facilitate your credentialing process.