REQUIREMENTS & INSTRUCTIONS - MENTAL HEALTH COUNSELOR LICENSE APPLICATION
Access this form via website at: cca.hawaii.gov/pvl
NOTE: Individuals using the title "Mental Health Counselor" or practicing "Mental Health Counseling" ARE REQUIRED to
obtain a "Mental Health Counselor" license. Rehabilitation counselors, school counselors, educational counselors,
and other counselors ARE NOT required to obtain a "Mental Health Counselor" license UNLESS they are using the
title "Mental Health Counselor" or are practicing "Mental Health Counseling".
APPLICATION
FORM
Complete and sign the attached application form in black ink. Include a check for the application fee.
Failure to provide all the requested information will delay the processing of your application. Applicants
are subject to meeting all requirements in effect at time of filing. There is no "reciprocity" (or
recognition of Mental Health Counselor licensure) in another state.
SOCIAL SECURITY
NUMBER
Your Social Security Number is used to verify your identity for licensing purposes and for compliance with
the below laws. For a license to be issued you must provide your Social Security Number or your
application will be deemed deficient and will not be processed further.
The following laws require that you furnish your Social Security Number to our agency:
FEDERAL LAWS:
42 U.S.C.A §666(a)(13) requires the Social Security Number of any applicant for a professional license or
occupational license be recorded on the application for license; and
If you are a licensed health care practitioner, 45 C.F.R., Part 61, Subpart B, §61.7 requires the Social
Security Number as part of the mandatory reporting we must do to the Healthcare Integrity and Protection
Data Bank (HIPDB), of any final adverse licensing action against a licensed health care practitioner.
HAWAII REVISED STATUTES ("HRS"):
§576D-13(j), HRS requires the Social Security Number of any applicant for a professional license or
occupational license be recorded on the application for license; and
§436B-10(4), HRS which states that an applicant for license shall provide the applicant's Social Security
Number if the licensing authority is authorized by federal law to require the disclosure (and by the federal
cites shown above, we are authorized to require the Social Security Number).
LICENSURE - EDUCATION, EXPERIENCE, AND EXAMINATION METHOD
The National Counselor Examination for Licensure and Certification (NCE) is computer based. Therefore,
applications are accepted year round with no specific filing deadline. All education, practicum and
post-graduate experience MUST be completed prior to filing the application. Applications that
lack supporting documents required for exam or licensure will not be considered. After it has been
determined that you are eligible to sit for the examination, you will be mailed further information
regarding the exam and fee. For more information regarding the NCE examination, see www.nbcc.org
and www.nbcc.org/stateboardmap.
MHC-00 0421R
(CONTINUED ON PAGE 2)
DOCUMENTS
IN A FOREIGN
LANGUAGE
ALL DOCUMENTS must be in English. Documents that are in a foreign language must be translated in
English. The translator must be someone other than the applicant. The translator must also submit an
affidavit (see below example of affidavit). The affidavit must be signed before a notary public. Attach
the translation and the affidavit.
Example of translator's affidavit: The following is an example of a translator's affidavit and contains all
of the elements required.
"I swear that I am competent in both the English language and the ______________ language (language
of the document) and that this is a true and complete translation of the foreign language original."
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EDUCATION
(1) Arrange for an official graduate school transcript of your master's or doctoral degree from an
accredited educational institution in counseling or in an allied field related to the practice of mental
health counseling to be sent directly to our office. In addition, if you are listing graduate courses
from additional institutions, have an official transcript sent directly to our office for each school.
Transcripts may be sent by mail to the post office box listed below or electronically to
(2) Complete the attached "Coursework Form", which shall verify completion of a graduate program that
includes or is supplemented by graduate level coursework in counseling comprising a minimum
of 48 semester hours OR 72 quarter hours and include the subject areas listed below, with a
minimum of 3 graduate semester hours or 5 graduate quarter hours in each subject area:
a) Human Growth and Development; f) Appraisal of Human Behavior;
b) Social and Cultural Foundations; g) Tests and Measurements;
c) Counseling Theories and Applications; h) Research and Program Evaluation; and
d) Group Theory and Practice; i) Professional Orientation and Ethics.
e) Career and Lifestyle Development;
Courses that are listed on the "Coursework Form" must be found on the graduate school transcript. A
course may be applied only once and may not be repeated in any of the other areas. Attach the
completed form to your application along with a catalog description and syllabus for each course
listed on the "Coursework" form. Failure to provide a catalog description for each course listed will
delay the processing of your application.
Have your supervisor complete the attached "Practicum Verification Form", which shall verify the
completion of at least 2 academic terms of supervised mental health practicum intern experience of a
total of at least 6 graduate semester hours or 10 graduate quarter hours in a mental health counseling
setting, with a minimum of 300 hours of supervised client contact. Please note that your supervisor is
required to sign the form before a Notary Public and attach a brief summary of the duties that you
performed during the practicum.
If you have had multiple supervisors, please duplicate the verification form.
Attach the completed form to your application.
PRACTICUM
EXPERIENCE
POST-GRADUATE
EXPERIENCE
Have your supervisor complete the attached "Post-Graduate Verification Form", which shall verify
completion of 3,000 hours of post-graduate experience in the practice of mental health counseling with
100 hours of face-to-face clinical supervision completed in no less than two years and in no more than
four years. Please note that your supervisor is required to sign the form before a Notary Public and
attach a brief summary of the duties performed during the post-graduate period.
Attach the completed form to your application.
NOTICE TO ALL MENTAL HEALTH COUNSELORS REGARDING ACT 252
Act 252 (Effective July 5, 2007) allows an individual who graduated from an accredited educational
institution as specified in HRS §453D-7 (a)(1) before July 1, 2007, to verify that the practicum intern
experience and the post-graduate experience was completed by submitting written certification in
place of the notarized experience verification forms.
For the practicum intern experience, an official of the institution of higher education must provide
written certification attesting that the applicant completed the academic terms, graduate credit hours,
and supervised client contact hours specified in HRS §453D-7 (a)(2) and that the applicant's practicum
intern experience is equivalent to a mental health graduate level practicum program. The written
certification must be on official letterhead from the institution of higher education.
For University of Hawaii at Hilo (UHH) applicants: if you took any course numbered 699V or 799V, submit
a copy of the "Directed Reading or Research Course Form" required from UHH. If you took any thesis
course numbered 700 or 800, submit a copy of the "Thesis/Dissertation Form" required from UHH. Attach
these completed form(s) to your application.
For the post-graduate experience, an officer and the clinical supervisor of the agency at which the
applicant earned the post-graduate experience must provide written certification attesting that the
applicant has completed the hours of experience and supervision in HRS §453D-7 (a)(2) within the time
frame set forth in that subsection and that the applicant's post-graduate experience is equivalent to the
practice of mental health counseling. The written certification must be on official letterhead from the
agency where the applicant completed the post-graduate experience.
PRACTICUM AND
POST-GRADUATE
SUPERVISOR
Your supervisor must be a person who is licensed as a mental health counselor, psychologist,
clinical social worker, advanced practice registered nurse with a specialty in mental health,
physician with a specialty in psychiatry, or a marriage and family therapist during the entire
supervised period.
EXAMINATION
REQUIREMENT
All applicants shall pass the National Counselor Examination for Licensure and Certification (NCE).
Once your application is approved you are eligible to register for the National Board for Certified
Counselors (NBCC) NCE examination, and a registration form will be mailed to you.
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(CONTINUED ON PAGE 4)
POST-GRADUATE
EXPERIENCE
(cont'd)
The NCE registration form and exam fee must be mailed back to NBCC for you to take the NCE
examination. Please allow NBCC approximately up to 4 weeks processing time. You will be notified of
the scheduling process by email and postcard once your examination registration is processed.
Candidates must test within 6 months of notification by NBCC.
APPLICANTS WHO
ALREADY PASSED
THE NCE EXAM
If you have already taken and passed the NCE examination, you will not be required to re-take the exam.
Applicants must contact the National Board of Certified Counselors (NBCC) to have written
documentation sent directly to our office. You may need to comply with the NBCC's policies and fees,
if any.
Contact information for the NBCC:
Website: http://www.nbcc.org
Telephone: (336) 547-0607
FEES Attach appropriate amount made payable to: Commerce and Consumer Affairs. (check must be in U.S.
dollars and be from a U.S. financial institution.)
Application Fee (non-refundable) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 60.00
LICENSE FEES After all requirements are fulfilled, license fees will be due. Notification of amounts due will be sent to
you at the appropriate time.
For license issued between July 1 (2020, 2023) and June 30 (2021, 2024)
of the first year of the triennium pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $444.00
(License fee - $213 + Compliance Resolution Fund - $129 + 2/3 renewal - $102)
For license issued between July 1 (2021, 2024) and June 30 (2022, 2025)
of the second year of the triennium pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $350.00
(License fee - $213 + Compliance Resolution Fund - $86 + 1/3 renewal - $51)
For license issued between July 1 (2022, 2025) and June 30 (2023, 2026)
of the third year of the triennium pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $256.00
(License fee - $213 + Compliance Resolution Fund - $43)
NOTE: One of the numerous legal requirements that you must meet in order for your new license to be issued
is the payment of fees as set forth in this application. You may be sent a license certificate before the payment
you sent us for your required fees is honored by your bank. If your payment is dishonored, you will have failed
to pay the required licensing fee and your license will not be valid and you may not do business under that
license. Also, a $25.00 service charge shall be assessed for payments that are dishonored for any reason.
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If for any reason you are denied the license you are applying for, you are entitled to a hearing as provided by
Title 16, Chapter 201, Hawaii Administrative Rules, and/or Chapter 91, Hawaii Revised Statutes. Your written
request for a hearing must be directed to the agency that denied your application, and must be made within
60 days of notification that your application for a license has been denied.
GENERAL INFORMATION
Applications may be submitted online at: https://mypvl.dcca.hawaii.gov. You may also
submit your application by mail or hand-deiivery.
ADDRESS Mail to:
Mental Health Counselor Program
DCCA, PVL Licensing Branch
P.O. Box 3469
Honolulu, HI 96801
hawaii.gov/dcca/pvl
OR
Deliver to:
PVL Licensing Branch
335 Merchant Street, Room 301
Honolulu, HI 96813
Phone: (808) 586-3000
LICENSE FEES
(cont'd)
Instructions for "YES" Answers to questions (4) thru (6) of the Application for License (MHC-01)
A. The following documentation must be submitted with the license application. Applications for
license will not be considered without this material.
1. Questions 4 and 5 refers to complaints, charges of unlicensed activity, or pending disciplinary
actions for any profession, occupation, or license. If you answer "yes" to one or more of
these questions you must submit the following:
i. A detailed statement signed by you explaining the circumstances; and
ii. Copies of any documents from the agency, including final orders, petitions, complaints,
finding of facts and conclusions of law, proof of payment of any fines, and any other
relevant documents.
2. If your application indicates a criminal conviction you must submit the following:
i. A detailed statement signed by you explaining the circumstances leading to the
conviction and detailing all activities since the conviction, including employment and
business involvements. Include job title, period of employment, employers name,
description of duties, training attended, and educational courses attended; and
ii. A copy of all related court documents (i.e. indictments, judgements, guilty pleas,
the court order, verdict, and terms of sentence); and if applicable, proof of payment
of any fines and proof of fulfillment of conditions of each sentence; and
A current criminal history record check in your name from the state where the
conviction occurred and the state where you currently reside if different. In Hawaii,
you may obtain a criminal history record check from the Hawaii Criminal Justice Data
Center. Contact the Department of the Attorney General, Hawaii Criminal Justice Data
Center, Kekuanao'a Building 456 S. King Street, Room 101, Honolulu, HI 96813.
Ph: (808) 587-3100 or visit their website at: ag.hawaii.gov/hcjdc to request a
"Criminal History Record Check" form; and
iii. If applicable, a copy of the terms of probation and/or parole and a statement from
your probation or parole officer as to your compliance with the court orders.
TRIENNIAL
RENEWAL
All licenses, regardless of issuance date, shall be renewed triennially (every three (3) years) on or
before June 30, with the first renewal occurring on June 30, 2008. Failure to renew a license shall result
in a forfeiture of the license. Licenses which have been forfeited may be restored within one year of the
expiration date upon payment of the renewal and restoration fees. Failure to restore a forfeited license
within one year of the date of its expiration shall result in automatic termination of the license. Persons
with terminated licenses shall be required to apply for licensure as a new applicant.
It is the responsibility of the licensee to inform the Department in writing of any name or address change.
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RELEASE OF
INFORMATION
If an agency or individual is assisting you with the licensure process, we will not be able to release any
information to them unless you provide us with authorization. If you wish to do so, please complete the
portion on Release of Information to Third Party, sign and date it.
APPLICANTS WITH
SPECIAL NEEDS
If you are requesting special testing arrangements due to a disability, call (808) 586-2711 immediately to
obtain a Disability Certification Form which must be completed by an approved professional, and
submitted preferably prior to your exam application. Determination of qualification for special testing
arrangements will then be made and if so, the type of special testing arrangements to be provided.
No action will be taken to provide special testing arrangements until you have been approved to sit for
the exam.
LAWS & RULES To obtain a copy of the laws, Chapter 453D, Hawaii Revised Statutes, send a written request to Mental
Health Counselor Program, Commerce and Consumer Affairs, P.O. Box 3469, Honolulu, HI 96801. Indicate
the specific chapter in your request. Chapter 436B, Hawaii Revised Statutes, the Professional and
Vocational Licensing Act should be read in conjunction with Chapter 453D.
The laws are also posted on our website at: cca.hawaii.gov/pvl. Click on "Mental Health Counselor".
Then click on "Mental Health Counselor Laws and Rules (HRS/HAR)".
ABANDONMENT
OF APPLICATION
Pursuant to HRS §436B-9 your application shall be considered abandoned and shall be destroyed if you
fail to provide evidence of continued efforts to complete the licensing process for two consecutive years.
The failure to provide evidence of continued efforts includes but is not limited to: (1) failure to submit
any required information and documents requested by the licensing authority within two consecutive
years from the last date the documents and information were requested, or (2) failure to complete any
additional requirements for licensure that remain after approval of your application, such as attempting
to complete an exam requirement, within two consecutive years from the date your application was
approved, or (3) failure to provide the licensing authority with any written communication during two
consecutive years indicating that you are attempting to complete the licensing process. If an application
is deemed abandoned the applicant shall be required to reapply for licensure and comply with the
licensing requirements in effect at the time of the reapplication.
This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your request.
Print Form
APPLICATION FOR LICENSE - MENTAL HEALTH COUNSELOR
Access this form via website at: cca.hawaii.gov/pvl
Legal Name (First, Middle) (Last)
Other Names Used (Include maiden name)
Residence Address (Include Apt. No., City, State and Zip Code)
Mailing Address (ONLY if different from above)
Social Security No.
Phone No. (Days)
FOR OFFICE USE ONLY
APPROVED:
Initial/Date:
License No.
MHC -
Effective Date:
Answer all questions and check your answers. If any response to questions 4 through 6 is "YES", refer to the instructions for additional
documents that must be submitted with this application.
1) Are you at least 18 years of age? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
2) Are you a U.S. citizen, a U.S. national, or an alien authorized to work in the United States? . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
3) Have you taken and passed the NCE examination? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
If "YES", provide date verification was requested to NBCC:
4) Have you ever been denied a certificate or license to practice mental health counseling? . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
5) a. Has any license ever been suspended, revoked or otherwise subject to disciplinary action? . . . . . . . . . . . . . . . . . . . . . .
Yes No
b. Are there any disciplinary actions pending against you? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
c. Have you ever been disciplined for an ethical violation by a state or by a professional association? . . . . . . . . . . . . . . .
Yes No
6) Have you ever been convicted of a crime in any jurisdiction that has not been annulled or expunged? . . . . . . . . . . . . . .
Yes No
Complete the requested information below. Attach additional sheets if necessary.
Failure to complete the requested information will delay the processing of your application.
EDUCATION
Name of Institution Major Course of Study Date Degree Name of Degree Conferred Name of your Major
Name & Address of Experience
(Attach additional sheets if necessary)
List Your Duties
Dates (mo/day/yr)
Title of your Position
EXPERIENCE
From To
(CONTINUED ON PAGE 2)
MHC-01 0421R
Lic . . . . . . . 765 . . . . . . . . . . . . . . . . $213 Appl . . . . . . . . . . . . . . . . 760 . . . . . . . . . $60
CRF . . . . . . 763 . . . . . . . . . . . . . . . . $43/$86/$129 Renewal . . . . . . . . . . . . 767 . . . . . . . . . $51/$102
Service Charge. . . . . . BCF . . . . . . . . . $25
Date of Birth
Print Name of Applicant:
Affidavit of Applicant:
I certify that the statements, answers, and representations made in this application and the documents attached are true and correct.
I understand that any misrepresentation is grounds for refusal or subsequent revocation of license and is a misdemeanor (Section 710-1017,
Sections 436B-19 and 453D-12, Hawaii Revised Statutes).
I further certify that I have read, understand, and will abide by the provisions of Chapter 453D, Hawaii Revised Statutes, concerning
Mental Health Counselors in the State of Hawaii.
Signature of Applicant Date
Release of Information to Third Party:
To assist me in the licensing process, I authorize DCCA's staff to release any and all information regarding my application (including but
not limited to, application status) to the following third party:
Print Name of Individual who is assisting you:
Name of Organization:
Signature of Applicant Date
This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your request.
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Date:
Print Form
