Coursework Form - Mental Health Counselor Access this form via website at: cca.hawaii.gov/pvl

Instructions for filing "Coursework Form": • Each applicant must complete at least 48 semester hours or 72 quarter hours of GRADUATE LEVEL coursework that shall include the following subjects areas, with a minimum of 3 graduate semester hours or 5 graduate quarter hours in each subject area listed below. • Each course must be on your transcript and can only be listed one time on the form.

• Attach a catalog description and syllabus for each course listed on "Coursework Form".

• In each subject area indicate credits in semester hours (S) or in quarter hours (Q).

• FAILURE TO PROVIDE THE REQUESTED INFORMATION BELOW WILL DELAY THE PROCESSING OF YOUR APPLICATION.

Name of Applicant:

Social Security No.:

a. Human growth and development.

Institution Course Number Course Title Term Hours S or Q

Total Hours:

Institution Course Number Course Title Term Hours S or Q

Total Hours:

b. Social and cultural foundations.

c. Counseling theories and applications.

Institution Course Number Course Title Term Hours S or Q

Total Hours:

MHC-02 0818R

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d. Group theory and practice.

Institution Course Number Course Title Term Hours S or Q

Total Hours:

e. Career and lifestyle development.

Institution Course Number Course Title Term S or Q

Total Hours:

Hours

Date of Birth:

Each applicant must complete at least 48 semester hours or 72 quarter hours of graduate level coursework that shall include the following subject areas, with a minimum of 3 graduate semester hours or 5 graduate quarter hours in each subject area listed below. Each course must be on your transcript and can only be listed one time on the form.

f. Appraisal of human behavior.

Institution Course Number Course Title Term Hours S or Q

Total Hours:

g. Tests and measurements.

Institution Course Number Course Title Term Hours S or Q

Total Hours:

h. Research and program evaluation.

Institution Course Number Course Title Term Hours S or Q

Total Hours:

i. Professional orientation and ethics.

Institution Course Number Course Title Term Hours S or Q

Total Hours:

Practicum experience - You must have completed at least 2 academic terms of a total of at least 6 graduate semester hours or 10 graduate quarter hours.

Institution Course Number Course Title Term Hours S or Q

Total Hours:

TOTAL number of graduate semester hours or graduate quarter hours

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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 Name of Applicant: Date: