How to Fill Out Form 5CS: Certification of Supervisor for Limited Permit

Form 5CS, the Certification of Supervisor for Limited Permit, is the New York State Education Department form your proposed supervisor signs to confirm they will oversee your practice while you finish the requirements for a mental health license. You complete Section I with your own information, your supervisor completes Section II with their credentials and signature, and the form goes to NYSED together with your Form 5 limited permit application and the $70 fee.¹

Download the Right Version First

NYSED publishes a separate Form 5CS for each of the five mental health professions it licenses under Article 163. Before you start, make sure you have the one that matches the license you are pursuing:

The layout is the same across all five, but the supervisor-qualification language is tailored to each profession. Using the wrong version will delay your application.

Section I: What You Fill In

Section I is short. You provide your full legal name, date of birth, and the Application ID number generated when you filed your Form 5 limited permit application online. When you hand the form to your proposed supervisor, include a copy of Appendix A, the Requirements for Supervised Experience document for your profession, so they can see exactly what NYSED expects them to certify.²

If you plan to work under more than one supervisor, or at more than one authorized site, you need a separate Form 5CS for each supervisor.

Section II: What Your Supervisor Fills In

Section II is where the supervisor certifies they meet NYSED’s qualifications, identifies the practice site or sites where you will be working, and signs. Two limits apply across all five professions: a supervisor may not oversee more than five limited permit holders at one time, and the supervisor cannot be a relative or someone with a personal relationship to you.¹

The credentials the supervisor must hold vary by profession. For marriage and family therapy, the supervisor must hold a current New York license and registration as a marriage and family therapist, physician, physician assistant, psychologist, licensed clinical social worker, or registered professional nurse or nurse practitioner, and must be competent in marriage and family therapy. An out-of-state supervisor must hold qualifications the Department deems equivalent.¹ For licensed clinical social work, the supervisor must be a licensed clinical social worker providing general supervision as defined in the Commissioner’s regulations.⁶ Check Appendix A for your profession to confirm what your specific supervisor needs.

Look over Section II before you send anything in. An incomplete supervisor section is one of the most common reasons applications stall.³

How To Submit the Completed Form

You have two ways to get Form 5CS to NYSED.

Online. If you are filing your limited permit application now, upload Form 5CS as part of the online Form 5 submission through the NYSED eservices portal. If your application is already in, upload the form separately at eservices.nysed.gov/professions/wf/document using your Application ID and date of birth.¹

By mail. Send the form to the New York State Education Department, Office of the Professions, 89 Washington Avenue, Albany, NY 12234-1000. Address it to the specific unit for your profession, such as the Marriage and Family Therapy Unit or the Mental Health Counseling Unit.¹

Either way, Form 5CS travels with your Form 5 and the $70 nonrefundable permit fee. NYSED will not process the permit without all three.⁷

After You Submit

NYSED asks applicants to wait at least six weeks after all documentation is in before requesting a status update.⁸ You cannot begin practicing, or begin counting supervised experience toward licensure, until the permit is actually issued.⁹

A limited permit is valid for two years. If you have not passed your exam or completed your experience by then, NYSED may renew it for up to two additional one-year periods, but only where the Department finds you made good-faith efforts to complete the requirements. Each renewal is another $70.⁷

When You Will Need Another Form 5CS Later

Your permit is tied to the specific supervisor and practice site listed on it. If your supervisor leaves, you change practice sites, or you add a new location, you have to apply for an amended permit before working under the new arrangement. Use the online Limited Permit Change Form through NYSED eservices and submit a new Form 5CS for each new supervisor. There is no fee for an amended permit tied to a supervisor or setting change.¹⁰

Do not start at the new site or under the new supervisor until the amended permit is issued. NYSED may refuse to credit experience gained outside the terms of a valid permit.⁹

1
New York State Education Department. Marriage and Family Therapist Form 5CS – Certification of Supervisor for Limited Permit
2
New York State Education Department. Application Forms for Mental Health Counselors
3
New York State Education Department. Application Forms for Licensed Clinical Social Worker
4
New York State Education Department. href=”https://www.op.nysed.gov/professions/creative-arts-therapists/application-forms/form-5″ target=”_blank” rel=”noopener”>Online Form 5 – Application for Limited Permit for Creative Arts Therapists
5
New York State Education Department. Application Forms for Psychoanalysts
6
New York State Education Department. Section 74.4 Limited Permits
7
New York State Education Department. Article 163, Mental Health Practitioners
8
New York State Education Department. Mental Health Counselors Status
9
New York State Education Department. Limited Permits – Creative Arts Therapists
10
New York State Education Department. Online Form 5 – Application for Limited Permit for Licensed Master Social Worker