Mental Health Counselor Associate Supervision and Experience Verification DOH 670-128 This form prov 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section 1, print or type your name clearly, including your last, first, and middle names. Enter your birth date and address details accurately.
3. Proceed to fill in the Approved Supervisor section. Provide the supervisor's name, current phone number, credential state, and their first issuance date along with their address.
4. For the Supervised Postgraduate Experience section, indicate the dates of supervision. Ensure you document the total months supervised and break down the hours into immediate supervision, direct counseling hours, and all other supervised hours.
5. Finally, have your supervisor sign and date the form to certify that all information is accurate. Make sure to review everything before submission.

Start using our platform today for free to streamline your form completion process!