Free NCMHCE Practice Test
Work through 40 original, unofficial questions in four counseling case studies, each with the answer and a full explanation — no signup. Like the real exam, each case moves from an intake to two later sessions; this set follows the NCMHCE content outline for exams taken before July 1, 2027.
Case Study 1: Marcus
Part 1 — Intake
Setting: Private practice; all sessions by secure video. You are licensed in the state where Marcus lives.
1. Marcus joins the first video session from his bedroom with the door closed. Before you begin clinical work, what should you do first?
Reveal answer and explanation for question 1
Answer: C. Video counseling adds items to ordinary informed consent: emergency procedures and what happens if the technology fails. Knowing the client's exact location matters because local emergency services have to be reached where he is, not where you are. That's why the plan also includes nearby emergency contacts and a backup if the call drops.
- A is wrong because counselors must tell clients about the built-in limits of confidentiality when technology is used, not promise equivalence.
- B puts clinical content ahead of the consent and safety groundwork.
- D turns a reasonable expectation into an ultimatum, and it isn't the first priority.
Domain: Professional Practice and Ethics · Sources: ACA Code of Ethics (2014) (PDF) H.2.a, H.2.c; HHS, "Creating a telehealth emergency plan"
| Case detail | Information |
|---|---|
| Client | Marcus, 34, male; lives with his partner, Dana, and her two children |
| Referral | Self-referred after his primary care provider suggested counseling |
Presenting problem. Seven weeks ago, while working as a rideshare driver, Marcus was carjacked at gunpoint at a red light late at night. He was not physically hurt. Since the first week he has had nightmares about the gun "almost every night," and he jolts when a car horn sounds. He has stopped taking evening shifts and won't drive after dark, which has cut his income by about a third. "I keep thinking I should've seen him coming. I'm the one who stopped at that corner." He quit his weekly basketball league because "I just don't care about it anymore." Dana says he "snaps over nothing." He sleeps about four hours a night. Before the carjacking he had one or two beers on weekends; for the past month he has had three or four most nights "so I can fall asleep." He denies thoughts of suicide or of harming anyone and has never been in counseling.
Mental status exam. Alert and oriented ×4. Casually dressed, good hygiene. Repeatedly glances at the doorway behind him during the call. Mood "on edge"; affect anxious and constricted. Speech normal in rate and volume. Thought process linear; thought content focused on the robbery and self-blame. No hallucinations or delusions. Insight and judgment fair.
2. Based on the intake, which diagnosis is best supported?
Reveal answer and explanation for question 2
Answer: B. Walk the criteria:
- Exposure: threatened death at gunpoint.
- Intrusion: nightmares.
- Avoidance: refusing to drive after dark.
- Negative thinking or mood (at least two): self-blame and lost interest in basketball.
- Arousal (at least two): startle, irritability, poor sleep, and scanning the doorway.
- Duration and impairment: more than one month (seven weeks), with real impairment (lost shifts and income).
The trauma-linked symptoms began before his drinking increased, which supports PTSD as the leading diagnosis. A complete assessment must still determine whether medication, substance use, or another illness accounts for the symptoms. His drinking also needs assessment.
- A covers the first month after a trauma. At seven weeks, PTSD is the diagnosis to consider.
- C is used when a stress reaction doesn't meet criteria for a more specific disorder. Marcus's trauma-specific symptom pattern and duration favor PTSD, subject to completing the diagnostic assessment.
- D describes broad worry across many areas, not re-experiencing and avoidance tied to one event.
Domain: Intake, Assessment, and Diagnosis · Sources: DSM-5-TR (American Psychiatric Association, 2022), PTSD Criteria A–H, as summarized in VA National Center for PTSD, "PTSD and DSM-5"; VA, Acute Stress Disorder, What is acute stress disorder?
3. What is the best way to address Marcus's drinking at this point?
Reveal answer and explanation for question 3
Answer: D. Substance use is a core intake task, and PTSD commonly co-occurs with alcohol problems. A structured screen plus interview gives you the information a diagnosis requires.
- A skips the assessment. Alcohol use disorder (AUD) requires at least two of 11 specific criteria in the past year, and the intake hasn't gathered them.
- B sets a condition before you know what you're dealing with.
- C ignores a known risk just because the drinking has a reason.
Domain: Intake, Assessment, and Diagnosis · Sources: NIAAA, Understanding Alcohol Use Disorder, symptoms and severity; NIAAA, Screen and Assess: Use Quick, Effective Methods, screening methods and follow-up after a positive screen; VA, Treatment of Co-Occurring PTSD and Substance Use Disorder, Key Points and Prevalence and Characteristics; ACA Code (PDF) E.6.a
4. Marcus says, "I keep replaying it. I should've seen him coming." Which response is most empathic?
Reveal answer and explanation for question 4
Answer: A. It reflects both the content (self-blame) and the feeling (exhaustion) without arguing or judging.
- B may be true, but it tells him what to feel and closes the conversation. Here, the task is to reflect his experience, not to challenge the belief.
- C is a "why" question that reads as an accusation and feeds the self-blame.
- D minimizes what happened.
Domain: Core Counseling Attributes · Sources: SAMHSA TIP 35 (2019), Chapter 3, Reflective Listening; NCMHCE Content Outline (PDF), task 6.H (coverage)
Part 2 — Session 1 (three weeks after intake)
Marcus tracked his drinking for two weeks and is down to one or two beers, three nights a week. The nightmares continue. He still won't drive after dark, and he skipped a family dinner across town because it ended after sunset. You explain that trauma-focused therapies are among the most effective treatments for PTSD. He asks, "Am I going to have to describe the whole thing out loud? My cousin said talking about it makes it worse."
5. How should you respond to his question?
Reveal answer and explanation for question 5
Answer: C. Clients are entitled to know the purpose, techniques, risks, and benefits of what's offered, and plans are built jointly. Prolonged exposure (PE), cognitive processing therapy (CPT), and EMDR all have strong evidence for PTSD, so the choice is a shared decision. They differ in how much they ask you to recount the event: in PE, detailed recounting usually starts around the third session and may bring brief, mild-to-moderate discomfort. You can only offer what you're trained to provide.
- A is a promise you may not be able to keep, and it quietly removes effective options.
- B pressures him and skips his right to choose.
- D leaves his question unanswered and delays the decision treatment depends on.
Domain: Professional Practice and Ethics · Sources: ACA Code (PDF) A.1.c, A.2.b, C.2.a; VA National Center for PTSD, "Overview of Psychotherapy for PTSD"; VA, "Prolonged Exposure (PE) for PTSD"
6. Marcus chooses prolonged exposure and agrees to work on night driving in objectively safe conditions. Which intervention fits that approach?
Reveal answer and explanation for question 6
Answer: B. Avoidance feels better in the moment but keeps PTSD going. Prolonged exposure makes a list of avoided situations and works through it step by step, starting with what's manageable.
- A prescribes the avoidance that maintains the problem.
- C can support coping, but relaxation alone doesn't address the avoidance.
- D is an interpretive approach, not exposure.
Domain: Counseling Skills and Interventions · Source: VA, "Prolonged Exposure (PE) for PTSD"
7. You and Marcus agree that a 15-minute route at dusk is a safe, feasible starting step. Which is the best short-term objective for his treatment plan?
Reveal answer and explanation for question 7
Answer: D. It specifies the agreed activity, frequency, time frame, and a way to monitor distress. Its feasibility comes from the assessment and agreement described in the stem.
- A and B are reasonable long-term aims, but they can't be measured as written.
- C isn't realistic, and trying not to think about the trauma is a form of avoidance.
Domain: Treatment Planning · Sources: ACA Code (PDF) A.1.c; VA, Prolonged Exposure (PE) for PTSD, What can I expect? and Will I have homework?; NCMHCE Content Outline (PDF), task 4.B (coverage)
Part 3 — Session 2 (six weeks after intake)
Marcus has driven the dusk route four times; his distress ratings fell from 8 to 5. At his request, Dana joins the last 15 minutes. She says, "He's better with the driving, but he still snaps at me and the kids over little things." Marcus looks down: "I hate that I'm like this." After the session, Marcus asks you not to discuss his drinking with Dana. Two days later, Dana calls you: "How is he really doing? Is he still drinking?"
8. How should you respond to Dana's call?
Reveal answer and explanation for question 8
Answer: A. Marcus has not authorized this disclosure, and no exception to confidentiality is presented. Marcus explicitly asked you not to discuss his drinking. Joining 15 minutes at his invitation didn't make Dana a client or give her access to his information.
- B, C, and D all disclose without authorization. Good news and good intentions don't change that.
Domain: Professional Practice and Ethics · Source: ACA Code (PDF) B.1.c, B.6.g
9. In the joint segment, what is the most helpful response to the irritability Dana describes?
Reveal answer and explanation for question 9
Answer: C. Irritability is one of the listed PTSD arousal symptoms. Naming it that way reduces blame on both sides, and a shared plan turns the insight into a skill.
- A shames him and ignores the symptom.
- B makes Dana responsible and builds more avoidance into the household.
- D might help later, but it skips the immediate, in-scope intervention.
Domain: Counseling Skills and Interventions · Sources: VA, "PTSD and DSM-5", Criterion E; VA, Anger and Trauma, How can you get help with anger? and For behavior
10. Which approach would best show whether Marcus's PTSD symptoms are changing over time?
Reveal answer and explanation for question 10
Answer: B. The PCL-5 is a 20-item self-report checklist of DSM-5 PTSD symptoms. The VA describes it as a tool for screening and for monitoring change during treatment. A score informs your judgment; it doesn't replace it.
- A is one unstructured question.
- C comes too late to guide treatment and relies on a third party.
- D measures attendance, not symptoms.
Domain: Intake, Assessment, and Diagnosis · Sources: VA National Center for PTSD, "PTSD Checklist for DSM-5 (PCL-5)"; NCMHCE Content Outline (PDF), tasks 2.T–2.U
Case Study 2: Ray
Part 1 — Intake
| Case detail | Information |
|---|---|
| Client | Ray, 61, male, married 36 years to Lorraine |
| Setting | Outpatient community agency; individual counseling |
| Referral | Lorraine made the appointment |
Presenting problem. Ray retired five months ago after 34 years teaching high school auto shop. "I'm only here because Lorraine says I drink too much. After 34 years, I've earned the right to relax." Since retiring, he drinks five or six beers a day, usually starting at lunch; before, he drank mostly on weekends. Twice he decided to drink "only after five" and couldn't keep it up for more than a few days. He stopped going to his grandson's baseball games this spring because he'd "rather stay home and have a few." He and Lorraine argue about his drinking most weeks, but he hasn't changed it. At a checkup last month, his doctor told him his liver tests were elevated, explained that drinking was worsening his liver health, and advised cutting back; Ray says he understood but "hasn't gotten around to it." He denies ever having shakes, sweats, or other symptoms when he goes without drinking, and he doesn't drive after drinking. He misses his students and coworkers: "Mornings are long now." He denies thoughts of suicide.
Mental status exam. Alert and oriented ×4. Casually dressed, well groomed. Mood "fine"; affect euthymic, turning irritable when drinking comes up. Speech normal. Thought process linear; no suicidal or homicidal ideation. Insight limited; judgment fair.
11. Ray opens with, "I'm only here because Lorraine says I drink too much." Which response is best?
Reveal answer and explanation for question 11
Answer: D. Reflecting a reluctant client's statement, instead of challenging it, keeps the conversation open. Arguing for change can create discord.
- A argues with him in the first minute.
- B asks him to accept a label.
- C jumps to an action plan before he has agreed there's a problem.
Domain: Counseling Skills and Interventions · Source: SAMHSA TIP 35 (2019), Chapter 3, Reflective Listening and A New Look at Resistance
12. Based on the intake, which DSM-5-TR classification best fits Ray's drinking?
Reveal answer and explanation for question 12
Answer: C. Count the past-year criteria the intake documents:
- Unsuccessful efforts to cut down.
- Continued drinking despite recurring conflict with Lorraine.
- Giving up an important activity (his grandson's games) to drink.
- Continued drinking despite knowing it is worsening a physical health problem.
Severity runs mild = 2–3 criteria, moderate = 4–5, severe = 6 or more, so four criteria is moderate.
- A is wrong because the criteria are met and causing harm.
- B undercounts.
- D would need at least six. He denies withdrawal, and the intake describes no tolerance, craving, or hazardous use.
Domain: Intake, Assessment, and Diagnosis · Source: NIAAA, "Understanding Alcohol Use Disorder" (DSM-5 criteria and severity levels)
13. Ray mentions his doctor is "keeping an eye on" his liver tests. You want to send a counseling summary to coordinate care, and no exception to confidentiality applies. What should you do?
Reveal answer and explanation for question 13
Answer: A. For this routine disclosure of counseling records, the ACA Code calls for written permission.
- B discloses without consent when there's no emergency.
- C misses the collaboration his care needs.
- D makes a medical determination from limited information instead of coordinating care and discussing the risks with Ray.
Domain: Treatment Planning · Sources: ACA Code (PDF) B.6.g, B.2.e; NCMHCE Content Outline (PDF), task 4.N
Part 2 — Session 1 (two weeks later)
At your suggestion, Ray kept a drinking log; it shows about five beers a day. "Seeing it written down was something. Maybe I'm drinking more than I should. But honestly, a cold beer is the only thing I look forward to since I retired. I don't know."
14. Regarding reducing his drinking, which stage of change best describes Ray now?
Reveal answer and explanation for question 14
Answer: B. He acknowledges a concern ("maybe I'm drinking more than I should") and is ambivalent ("a cold beer is the only thing I look forward to... I don't know"). That's contemplation.
- A fits his stance at intake, but he has moved since then.
- C involves considering specific options and planning first steps. He hasn't gotten there.
- D involves actively changing the target drinking behavior; keeping a log alone does not establish that stage.
Domain: Counseling Skills and Interventions · Source: SAMHSA TIP 35 (2019), Chapter 1, TTM of the SOC, stage descriptions
15. Which statement is a double-sided reflection?
Reveal answer and explanation for question 15
Answer: A. A double-sided reflection holds both sides of the client's ambivalence in one statement, using things he has said.
- B is advice.
- C is a closed question.
- D applies a label that invites argument.
Domain: Counseling Skills and Interventions · Source: SAMHSA TIP 35 (2019), Chapter 3, Responding to change talk and sustain talk: Double-sided reflections
16. Which factor is most important to address in Ray's plan as a barrier to change?
Reveal answer and explanation for question 16
Answer: D. Ray links his drinking directly to retirement ("mornings are long"; beer is "the only thing I look forward to"). Building other sources of satisfaction to compete with drinking is a core motivational strategy.
- A may affect his drinking, but the clearest barrier he identifies is the loss of routine and rewarding activities.
- B isn't a barrier in itself.
- C hasn't been established, and it can't be changed.
Domain: Treatment Planning · Source: SAMHSA TIP 35 (2019), Chapter 7, Support the Client's Lifestyle Changes and Replacement Activities
Part 3 — Session 2 (five weeks after intake)
Ray tells you he's decided to "cut back, not quit." For nine days he held to two beers a day. Then, at a former coworker's retirement party, he drank "probably ten." He drops into the chair: "See? I can't do this. I'm kidding myself." Later, he mentions Lorraine wants to "sit in on these and keep me honest." You've noticed you felt irritated with Ray in the last two sessions. Your own father drank heavily, and Ray's jokes about drinking remind you of him.
17. Given his elevated liver tests, how should you handle Ray's goal to cut back rather than quit?
Reveal answer and explanation for question 17
Answer: C. Motivational approaches pair clear, nonjudgmental information with the client's responsibility for change and a menu of options. Coordinating with his doctor (with permission) takes the medical question to the person qualified to answer it.
- A pushes faster than he's ready to go, which risks breaking the working relationship.
- B withholds information he needs.
- D offers one path, when treatment for alcohol problems isn't one-size-fits-all.
Domain: Treatment Planning · Sources: SAMHSA TIP 35 (2019), Chapter 3, Developing a Change Plan; NIAAA, Conduct a Brief Intervention, Give feedback and advice; ACA Code (PDF) A.1.c; NIAAA, Understanding Alcohol Use Disorder, treatment options
18. How should you respond to "See? I can't do this"?
Reveal answer and explanation for question 18
Answer: B. A return to heavier drinking is an event to learn from, not proof of failure. Looking at what happened just beforehand identifies triggers and better choices for next time.
- A agrees with his hopelessness.
- C makes escalation sound like a consequence of not sticking to the plan. A higher level of care may be appropriate after assessment; one setback alone does not determine that decision.
- D is kind but skips the learning.
Domain: Counseling Skills and Interventions · Sources: SAMHSA TIP 35 (2019), Chapter 7, Provide Relapse Prevention Counseling and Relapse management strategies; NIAAA, Understanding Alcohol Use Disorder, treatment settings
19. What should you do about your reactions to Ray?
Reveal answer and explanation for question 19
Answer: D. Counselors monitor their own effectiveness and seek supervision when something personal may be affecting their work. Catching countertransference early is the professional move.
- A is self-disclosure that serves you, not him.
- B is premature. Awareness of a reaction alone does not establish whether it is impairing your work; assess its impact through supervision or consultation.
- C leaves an unexamined reaction free to shape your work.
Domain: Core Counseling Attributes · Sources: ACA Code (PDF) C.2.d, C.2.g; NCMHCE Content Outline (PDF), task 6.A
20. How should you respond to Lorraine's request to join sessions?
Reveal answer and explanation for question 20
Answer: A. Involving a support person often helps, but only with the client's consent. When more than one person is in the room, roles and confidentiality need to be settled at the start.
- B skips Ray's consent.
- C states a rule that doesn't exist.
- D violates basic documentation standards.
Domain: Professional Practice and Ethics · Source: ACA Code (PDF) A.1.b, A.1.d, A.8, B.4.b
Case Study 3: Jordan
Part 1 — Intake
| Case detail | Information |
|---|---|
| Client | Jordan, 19, female, college sophomore; lives in a residence hall with a roommate |
| Setting | Community counseling clinic near campus; individual counseling |
| Referral | Her resident advisor |
Presenting problem. For the past five weeks Jordan has felt "heavy and sad basically every day." She stopped going to soccer practice ("it's pointless now"), sleeps 10 to 11 hours and still wakes up exhausted, has missed about half her classes, and can't concentrate on readings. She has lost about 8 pounds without trying because "nothing tastes like anything." She says, "I'm wasting my parents' money. They'd be better off if I just dropped out." Near the end of the intake, she adds quietly, "Sometimes I wish I could just not wake up." She is the first in her family to attend college; her parents live two hours away. She has "a couple" of drinks at parties most weekends. You have not yet asked about any past periods of unusually high mood or energy.
Mental status exam. Alert and oriented ×4. Wearing a hoodie; hair unwashed. Psychomotor slowing; speech soft and slow, with long pauses. Mood "empty"; affect flat and congruent. Thought content centered on worthlessness and guilt. No hallucinations or delusions. Insight and judgment fair.
21. After Jordan says she sometimes wishes she could "just not wake up," what should you do next?
Reveal answer and explanation for question 21
Answer: C. A passive wish to be dead still calls for a direct, structured risk assessment. You can't choose the right response until you know the frequency, plan, intent, means, and history.
- A leaves risk unassessed.
- B commits to the most restrictive option before you have the information to justify it.
- D discloses information before obtaining Jordan's permission or establishing an applicable exception.
Domain: Intake, Assessment, and Diagnosis · Sources: NIMH, Adult Outpatient Brief Suicide Safety Assessment Guide, Frequency of suicidal thoughts, Suicide plan, and Past behavior; ACA Code (PDF) B.1.c, B.2.a
22. Before you confirm a diagnosis of major depressive disorder, what must you ask about?
Reveal answer and explanation for question 22
Answer: A. A history of mania or hypomania can change the diagnosis from major depressive disorder (MDD) to a bipolar disorder. A depressive episode can be part of a bipolar disorder, and missing that changes treatment.
- B, C, and D may add context, but none is a diagnostic requirement for MDD.
Domain: Intake, Assessment, and Diagnosis · Source: NIMH, Bipolar Disorder, How is bipolar disorder diagnosed?
23. Jordan asks, "Are you going to tell my parents?" What's the best response?
Reveal answer and explanation for question 23
Answer: D. Counselors explain the limits of confidentiality at the start and as needed. The general rule protects her information. The exceptions include acting to protect a client from serious and foreseeable harm. Specific legal duties vary by state, so the details you give should match your jurisdiction.
- A treats paying tuition as a right to her information.
- B is a promise no counselor can make.
- C invents an exception.
Domain: Professional Practice and Ethics · Source: ACA Code (PDF) B.1.c, B.1.d, B.2.a
24. Jordan says, "I'm wasting my parents' money. They'd be better off if I just dropped out." Which response is most empathic?
Reveal answer and explanation for question 24
Answer: B. It reflects her feeling and its weight without judging, arguing, or rushing to fix it.
- A adds guilt.
- C normalizes in a way that shrinks her experience.
- D examines the belief rather than reflecting the feeling this question asks you to address.
Domain: Core Counseling Attributes · Sources: SAMHSA TIP 35 (2019), Chapter 3, Reflective Listening; NCMHCE Content Outline (PDF), task 6.H (coverage)
Part 2 — Session 1 (two weeks after intake)
Jordan's boyfriend ended their relationship four days ago. Her thoughts of not waking up have become more frequent, and twice this week she thought about taking her roommate's prescription sleeping pills, which are kept in an unlocked drawer. She hasn't taken any and says she "probably wouldn't," but she isn't sure what she'd do "on a really bad night." She wants help staying safe. After a full risk assessment, you and your supervisor agree she can be treated as an outpatient with close follow-up. She denies current intent or preparatory behavior and has reliable support for close follow-up; she agrees to develop and use a concrete safety plan. She hasn't seen a doctor since starting college.
25. You and Jordan agree to build a written safety plan. Where should you start?
Reveal answer and explanation for question 25
Answer: A. The Stanley-Brown safety plan starts with personal warning signs, written in the client's words, because they tell her when to use the plan. The six core steps are:
- Warning signs.
- Internal coping strategies.
- People and places that provide distraction.
- People she can ask for help.
- Professionals and crisis lines, including 988.
- Making the environment safer.
The current Stanley-Brown resource also includes an optional seventh step: identifying reasons for living. This is the order of the written plan, not a reason to delay addressing immediate safety or access to medication.
- B belongs in the plan, but at step 5, not as the starting point.
- C gives her no steps to follow and does nothing about access to means.
- D promises availability you can't sustain. The plan has to work when you're unreachable.
Domain: Counseling Skills and Interventions · Sources: Stanley-Brown Safety Planning Intervention, Steps to the Stanley-Brown Safety Plan; VA/DoD Safety Plan Worksheet (December 2024) (PDF), p. 1; NIMH, Adult Outpatient Brief Suicide Safety Assessment Guide, Make a safety plan
26. What's the best way to address the roommate's sleeping pills?
Reveal answer and explanation for question 26
Answer: C. Reducing access to medication is part of making the environment safer. Agree on a specific plan, who will carry it out, and how you will confirm it; address access promptly rather than waiting for a crisis. For example, with Jordan's agreement, her roommate could lock up the pills or keep them elsewhere so Jordan cannot access them.
- A is outside your role.
- B ignores means she can easily reach.
- D treats prescribed medication as misconduct and does not establish a safety plan.
Domain: Counseling Skills and Interventions · Sources: VA/DoD, Lethal Means Safety Counseling: Recommendations for Providers (December 2024) (PDF), p. 1, collaborative planning, medication storage, and follow-up; NIMH, Adult Outpatient Brief Suicide Safety Assessment Guide, Make a safety plan
27. Jordan hasn't seen a doctor since starting college, has lost weight, and sleeps 10 to 11 hours. What referral is most appropriate?
Reveal answer and explanation for question 27
Answer: D. Medical conditions can produce or worsen depressive symptoms, and a psychiatric evaluation addresses whether additional treatment would help. Obtain Jordan's consent for routine coordination and follow applicable confidentiality rules when sharing information or records.
- A skips concurrent care she may need.
- B and C treat single symptoms in isolation.
Domain: Treatment Planning · Sources: NIMH, Depression, How is depression diagnosed? and How is depression treated?; ACA Code (PDF) B.6.g
Part 3 — Session 2 (five weeks after intake)
Jordan's roommate now keeps the medication in a locked container Jordan cannot open. Jordan has used her safety plan twice, once by calling her older cousin. The thoughts of not waking up are "rare now," with no thoughts of acting on them. Her doctor found no medical cause and referred her to a psychiatric provider; the appointment is next week. She's attending most classes and went to one soccer practice. Her PHQ-9 depression score is lower than at intake. She mentions that her mother always says, "In our family we don't tell outsiders our business," and that she hasn't told her parents she's in counseling. Winter break starts in two weeks; she'll spend six weeks at her parents' home in another state and asks to keep meeting by video.
28. How should you use Jordan's lower PHQ-9 score?
Reveal answer and explanation for question 28
Answer: B. Clients have a right to know their results, and plans are reviewed and revised with them. A score is most useful next to the client's own experience.
- A wastes the information.
- C uses a lower score alone to justify termination despite continuing assessment and treatment needs.
- D is unsafe. Risk assessment stays ongoing, whatever a score does.
Domain: Treatment Planning · Sources: ACA Code (PDF) A.1.c, E.1.b; NIMH, Adult Outpatient Brief Suicide Safety Assessment Guide, Determine disposition and follow-up; NCMHCE Content Outline (PDF), tasks 2.S, 4.L, 4.M (coverage)
29. How should you respond to what her mother says about "telling outsiders"?
Reveal answer and explanation for question 29
Answer: D. Counselors stay aware of the cultural meanings of confidentiality and privacy, respect different views about disclosure, and avoid imposing their own values.
- A and B impose your view of what she should do.
- C avoids something that clearly matters to her.
Domain: Core Counseling Attributes · Source: ACA Code (PDF) A.4.b, B.1.a
30. Jordan wants to keep meeting by video from her parents' home in another state over break. What should you do first?
Reveal answer and explanation for question 30
Answer: C. Distance counseling can be subject to the laws of both the counselor's location and the client's. Licensure rules, including temporary practice rules or applicable interstate arrangements, depend on the specific states involved, so check first. If you can't serve her there, help her find services instead of leaving a gap. Her safety plan's local crisis contacts also need to match where she'll actually be.
- A and B skip the jurisdiction question.
- D risks abandoning a client with recent suicidal thoughts.
Domain: Professional Practice and Ethics · Sources: ACA Code (PDF) A.12, H.1.b, H.4.d; HHS, "Creating a telehealth emergency plan"; HHS, Licensing across state lines, Cross-state licensure and Temporary practice laws
Case Study 4: Evelyn
Part 1 — Intake
| Case detail | Information |
|---|---|
| Client | Evelyn, 68, female, widowed |
| Setting | Private practice; individual counseling |
| Referral | Her daughter, Anne |
Presenting problem. Evelyn's husband, Walter, died 14 months ago after a three-year illness during which she was his main caregiver. She describes intense longing for him "every single day" and says she thinks about him "almost all the time." She still sets a place for him at dinner. She stopped going to the church choir she sang in for 30 years because "everyone asks about Walter," and she takes a long detour to avoid the road to the hospital. "It's like half of me died with him." She feels "numb" around her grandchildren and can't picture a future. She hasn't returned to her volunteer work since the funeral. She sleeps about six hours and eats regular meals "because Anne makes me." Asked about her mood apart from missing Walter, she says, "If I could have him back, I'd be fine." She has one glass of wine on Sundays and uses no drugs. Partway through the intake she says, "Sometimes I just want to be with Walter."
Over at least the past month, the yearning, preoccupation, identity disruption, avoidance, numbness, and difficulty reengaging have been present nearly every day. After exploring Evelyn's social, cultural, and religious mourning practices, you find that the intensity and impairment exceed those expectations.
On the phone before the intake, Anne mentioned that Evelyn has missed two medical appointments this year and last month "got turned around" driving to the grocery store she has used for 20 years.
Mental status exam. Alert; oriented to person and place, unsure of the date ("around the middle of the month"). Neat and well dressed. Tearful when speaking of Walter. Mood "lost"; affect sad and congruent. Thought content centered on Walter. No hallucinations; she sometimes "talks to Walter" in the kitchen and knows he isn't there. Insight good.
31. Which provisional diagnosis is best supported?
Reveal answer and explanation for question 31
Answer: A. For adults, prolonged grief disorder requires at least 12 months since the death and intense yearning for, or preoccupation with, the deceased nearly every day. Evelyn is at 14 months with both. The case also establishes the required recent frequency, impairment, and grief exceeding her social, cultural, and religious expectations. The diagnosis remains provisional while the broader assessment continues. She also shows several of the additional symptoms DSM-5-TR lists, along with clear impairment (choir, volunteering):
-
Identity disruption ("half of me died").
-
Avoidance of reminders.
-
Emotional numbness.
-
Trouble moving forward.
-
B does not best explain the loss-focused pattern described; assess major depression separately rather than ruling it out from this vignette.
-
C does not account for the persistent impairment and symptom pattern exceeding the mourning expectations established in this case.
-
D is less specific than the grief-focused syndrome described; duration alone does not distinguish adjustment disorder.
Domain: Intake, Assessment, and Diagnosis · Source: American Psychiatric Association, Prolonged Grief Disorder, symptom frequency, adult duration threshold, impairment, and social/cultural/religious expectations
32. When Evelyn says, "Sometimes I just want to be with Walter," what should you do?
Reveal answer and explanation for question 32
Answer: B. The statement could mean she misses him, or it could mean suicidal thinking. Don't guess: ask directly and let her answer guide the assessment.
- A assumes the harmless reading.
- C reassures before you know what she means.
- D avoids the very thing you need to know.
Domain: Intake, Assessment, and Diagnosis · Sources: NIMH, Adult Outpatient Brief Suicide Safety Assessment Guide, Frequency of suicidal thoughts, Suicide plan, and Past behavior; NCMHCE Content Outline (PDF), task 2.S (coverage)
33. What best distinguishes Evelyn's presentation from major depressive disorder?
Reveal answer and explanation for question 33
Answer: A. Persistent loss-focused yearning and preoccupation favor prolonged grief disorder here. These features do not establish that other conditions are absent; complete the differential assessment rather than treating yearning as an exclusion rule.
- B isn't diagnostic.
- C is nonspecific.
- D doesn't distinguish the two, because a major depressive episode can follow a loss too.
Domain: Intake, Assessment, and Diagnosis · Sources: American Psychiatric Association, Prolonged Grief Disorder, characteristic symptoms and diagnosis; NIMH, Depression, types and diagnostic assessment
34. How should you respond to Anne's report and Evelyn's uncertainty about the date?
Reveal answer and explanation for question 34
Answer: C. Missed appointments, getting lost in a familiar place, and losing track of the date can signal cognitive problems that call for a doctor's evaluation, which can also look for medical causes.
- A and B risk missing a treatable or progressive medical problem.
- D goes far beyond what this information can establish.
Domain: Intake, Assessment, and Diagnosis · Source: NIH/NLM MedlinePlus, Alzheimer's Disease, symptoms and How is Alzheimer's disease diagnosed?
Part 2 — Session 1 (three weeks after intake)
Evelyn saw her doctor, who ordered tests; results are pending. She says the wish to "be with Walter" is about missing him, and she has no thoughts or plans of ending her life. She tells you, "Father Michael says Walter is at peace. But I can't feel God anymore, and I'm ashamed of that." She misses singing but can't face the choir "with everyone asking about Walter." You are not religious. Your own mother died four months ago, and twice this session you were close to tears and lost track of what Evelyn was saying.
35. What is the most appropriate step regarding your own reactions in this session?
Reveal answer and explanation for question 35
Answer: B. Counselors watch for signs that their own problems are affecting their work, seek help when they do, and limit their practice if necessary. Losing track of a client's words twice is a signal worth acting on. Steps may include your own support and, if needed, adjusting your caseload.
- A does not address the impairment already affecting your attention.
- C ignores a warning sign.
- D is abrupt. Counselors don't abandon clients, and transfers need pretermination counseling and a real handoff.
Domain: Core Counseling Attributes · Sources: ACA Code (PDF) A.11.c, A.12, C.2.g
36. How should you respond to "I can't feel God anymore, and I'm ashamed of that"?
Reveal answer and explanation for question 36
Answer: D. Exploring religious and spiritual values is part of counseling. Your job is to understand her experience, not supply your own beliefs.
- A sends away something she chose to bring to you. Her priest can support her alongside counseling, not instead of it.
- B imposes your worldview.
- C predicts an outcome you can't know.
Domain: Core Counseling Attributes · Sources: ACA Code (PDF) A.1.d, A.4.b; NCMHCE Content Outline (PDF), tasks 5.L, 6.J
37. Which intervention best helps Evelyn rebuild her support?
Reveal answer and explanation for question 37
Answer: A. It's collaborative and starts small. That could mean asking a trusted choir friend to go with her to one rehearsal and deciding ahead of time what she'll say when people ask about Walter.
- B selects a different choir before exploring which connection Evelyn wants to restore.
- C prescribes the step without exploring her preferences or barriers.
- D leaves her isolated with no plan.
Domain: Counseling Skills and Interventions · Sources: ACA Code (PDF) A.1.c, A.1.d; VA, Grief: Helping Someone Else After a Loss, Strategies for Offering Support
Part 3 — Session 2 (six weeks after intake)
Evelyn's doctor adjusted one of her medications and referred her for further memory testing. She says she feels "clearer" and has started using a wall calendar. She went to one choir rehearsal with her friend June and stayed for half of it. Then she says, "If I stop crying for him every day, it means I didn't really love him." With Evelyn's agreement, Anne joins for the last 15 minutes and asks, "Shouldn't she be over this by now? It's been more than a year."
38. How should you respond to "If I stop crying for him every day, it means I didn't really love him"?
Reveal answer and explanation for question 38
Answer: B. A reframe acknowledges the meaning behind her statement (loyalty and love) and opens room for other ways to express it.
- A argues with her.
- C judges her grief.
- D treats the crying as a behavior to reduce and ignores what it means to her.
Domain: Counseling Skills and Interventions · Sources: SAMHSA TIP 35 (2019), Chapter 3, Reframing; VA, Grief: Different Reactions and Timelines, Common Grief Reactions; NCMHCE Content Outline (PDF), task 5.AB (coverage)
39. Near the end of the session, which summary is best?
Reveal answer and explanation for question 39
Answer: D. A good summary pulls together the session's key content and feelings, including both progress and the open question, then checks that you got it right.
- A distorts where she is.
- B isn't a summary.
- C is vague and leaves out her progress.
Domain: Counseling Skills and Interventions · Sources: SAMHSA TIP 35 (2019), Chapter 3, Summarizing; NCMHCE Content Outline (PDF), task 5.AA (coverage)
40. How should you respond to Anne's question, with Evelyn present and agreeing to the conversation?
Reveal answer and explanation for question 40
Answer: C. Grief in itself isn't a disorder. The concern here is persistent, impairing symptoms that exceed Evelyn's cultural and religious expectations, not simply that a year has passed. Explaining that helps Anne support her mother instead of pressuring her.
- A imposes an unsupported deadline.
- B invents a timeline.
- D is unnecessary. Evelyn agreed to the conversation, so you can talk within what she has consented to.
Domain: Counseling Skills and Interventions · Sources: American Psychiatric Association, Prolonged Grief Disorder, symptoms and cultural context; VA, Grief: Different Reactions and Timelines, The Course of Grief; ACA Code (PDF) B.1.c
Hide all answers All 40 explanations and the answer key are open on this page.
Your practice results
Record your answer before revealing its key or explanation, and count one point for each correct first answer. If you answered all 40 before seeing their answers, divide your correct answers by 40 and multiply by 100—for example, 30 correct is 75%. If you skipped questions or revealed answers first, report "X correct from Y answered before reveal" instead of a full-set percentage.
Use this result to choose what to review. A short original practice set cannot establish whether you will pass the NCMHCE, and a percentage here is not an NCMHCE score. These four adult outpatient cases sample several NCMHCE domains; they don't cover every diagnosis, population, counseling setting, or type of clinical decision.
Answer key
Record your responses first if you want to self-score.
Show the complete answer key
| Q | Answer | Domain | Q | Answer | Domain |
|---|---|---|---|---|---|
| 1 | C | Ethics | 21 | C | Assessment |
| 2 | B | Assessment | 22 | A | Assessment |
| 3 | D | Assessment | 23 | D | Ethics |
| 4 | A | Attributes | 24 | B | Attributes |
| 5 | C | Ethics | 25 | A | Skills |
| 6 | B | Skills | 26 | C | Skills |
| 7 | D | Planning | 27 | D | Planning |
| 8 | A | Ethics | 28 | B | Planning |
| 9 | C | Skills | 29 | D | Attributes |
| 10 | B | Assessment | 30 | C | Ethics |
| 11 | D | Skills | 31 | A | Assessment |
| 12 | C | Assessment | 32 | B | Assessment |
| 13 | A | Planning | 33 | A | Assessment |
| 14 | B | Skills | 34 | C | Assessment |
| 15 | A | Skills | 35 | B | Attributes |
| 16 | D | Planning | 36 | D | Attributes |
| 17 | C | Planning | 37 | A | Skills |
| 18 | B | Skills | 38 | B | Skills |
| 19 | D | Attributes | 39 | D | Skills |
| 20 | A | Ethics | 40 | C | Skills |
By domain
The set mirrors the official scored-item weights of the current outline (40 × 15% = 6, 40 × 25% = 10, 40 × 30% = 12).
| Domain (current NCMHCE outline) | Official weight | Questions here | Your result before reveal |
|---|---|---|---|
| Professional Practice and Ethics | 15% | 6 (1, 5, 8, 20, 23, 30) | ___ correct from ___ answered |
| Intake, Assessment, and Diagnosis | 25% | 10 (2, 3, 10, 12, 21, 22, 31–34) | ___ correct from ___ answered |
| Treatment Planning | 15% | 6 (7, 13, 16, 17, 27, 28) | ___ correct from ___ answered |
| Counseling Skills and Interventions | 30% | 12 (6, 9, 11, 14, 15, 18, 25, 26, 37–40) | ___ correct from ___ answered |
| Core Counseling Attributes | 15% | 6 (4, 19, 24, 29, 35, 36) | ___ correct from ___ answered |
Areas of Clinical Focus (the presenting problems themselves) isn't scored as separate items on the NCMHCE; here it shows up as the four case presentations. Six to twelve questions per domain points you toward what to reread. It isn't a reliable measure of your ability in that domain.
Review what you missed
For each miss, name what the question was asking, find the case fact that decides it, and say why the strongest wrong option fits less well. Use these four patterns to examine a miss:
| If the mistake was… | Ask yourself… | Next step |
|---|---|---|
| Answering a different task | Was I asked to assess, respond empathically, plan, or intervene? | Restate the task in a few words, then compare the options again. |
| Assuming facts not supplied | Did I infer a diagnosis, permission, client preference, or completed assessment? | Point to the sentence that supports it. If there isn't one, drop the assumption. |
| Choosing a reasonable action at the wrong time | What has already happened at this stage of the case? | Reread that part's narrative, then the explanation. |
| Missing a principle or boundary | Which concept or ethical duty did I get wrong? | Read the cited source, write one sentence correcting it, and retry the question later. |
The four cases also repeat a handful of decisions that come up throughout case-based counseling questions:
- Establish the consent and telehealth safeguards the case requires. Location and emergency plans for video sessions; confidentiality limits at the start (Q1, Q23, Q30).
- Clarify any unclear risk statement directly. "Not wake up" and "be with Walter" both get a direct question, not an assumption (Q21, Q32).
- Use reflection when the task calls for empathy. In these items, acknowledging the client's experience fits better than arguing, advising, or judging (Q4, Q11, Q24).
- Explore the ambivalence described in the case. With Ray, acknowledge his reasons for and against change and agree on a next step he is willing to take (Q14, Q15, Q17).
- Assess before you label. Rule-outs, criteria counts, and medical causes come before a diagnosis (Q3, Q12, Q22, Q34).
- Check consent and disclosure exceptions. Obtain permission for the routine third-party involvement described here; serious foreseeable harm and legal requirements can create exceptions (Q8, Q13, Q20, Q23).
- Your reactions are information. Take them to supervision instead of acting on them or ignoring them (Q19, Q35).
How this practice compares with the NCMHCE
This is a 40-question study set across four cases, not a full-length exam.
| Feature | This page | Current NCMHCE (exams before July 1, 2027) | NCMHCE beginning July 1, 2027 |
|---|---|---|---|
| Case studies | 4 original cases | 11; one case study and some additional items are unscored | 10 |
| Questions | 40; first answers recorded before reveal count | 130–150 multiple choice; 100 scored | 130–150 multiple choice, including 30–50 unscored field-test items spread throughout |
| Case structure | Intake plus two later sessions | Intake plus two counseling sessions; 9–15 questions per case | Same structure; 9–15 questions per case |
| Answer format | Four options, one best answer | Four options, one correct answer | Four options |
| Going back | Reread anything, anytime | Review and change answers only within the current section; once you move on, earlier answers lock | Review allowed within each half; locked once submitted |
| Time | Untimed. A simple time-per-question estimate is roughly 60–70 minutes for 40, derived from 225 testing minutes for 130–150 questions. This is not an official time allowance; case-reading and explanation-review time vary. | 225 minutes of testing within a 255-minute session, with a scheduled 15-minute break after the fifth case study | 225 minutes, with an optional 15-minute break halfway |
| Scoring | Your count of correct answers | 1 point per scored question (maximum 100); the passing score is set through standard setting and equated across forms | Scaled scores from 100 to 500; 360 or higher passes. A scaled score is not a percentage. |
| Guessing | — | No penalty | Not stated in the 2027 specifications |
Sources: NCMHCE Content Outline, revised Oct. 8, 2025 (PDF) (Table 1; format and scoring, p. 9); NCMHCE Candidate Handbook for State Licensure, revised Nov. 20, 2025 (PDF) (pp. 8, 16, 21, 24); NCMHCE Examination Specifications, effective July 1, 2027 (PDF) (§§4–6).
Which version does this set follow?
It follows the current content outline, which applies to exams taken before July 1, 2027. What matters is your appointment date, not when you registered or bought study materials. On July 1, 2027, NBCC's new specifications take effect. They use different domains and weights:
- Professional Development & Counselor Self-Awareness: 15%
- Intake & Assessment: 18%
- Treatment Planning & Continuity of Care: 15%
- Provision of Counseling Interventions: 20%
- Indirect Client Care: 12%
- Legal & Ethical Compliance: 20%
The 2027 specifications explicitly include telemental health compliance, documentation, AI use in practice, and ICD-11 alongside DSM-5-TR. The case structure carries over, so these cases are still useful practice. If you test on or after July 1, 2027, check your coverage against the 2027 specifications (PDF); this set isn't mapped to that blueprint.
Quick answers
Is there an official free NCMHCE practice test? NBCC offers one free sample case study (PDF) with 13 questions. Another sample case appears in the candidate handbook's Appendix B. It shows the official format but doesn't include answer explanations.
What score do I need to pass? There's no fixed percentage on the current exam. A panel establishes the passing standard, and statistical equating adjusts the cut score for other forms according to their difficulty, so passing scores vary slightly from form to form. From July 1, 2027, scores are reported on a 100–500 scale, and 360 passes.
Can I take it online? Yes. NBCC offers the NCMHCE at Pearson VUE test centers and online through OnVUE. Online, the scheduled 15-minute break is the only break; unscheduled breaks aren't allowed. At a test center you can take extra breaks, but the clock keeps running. See the handbook (PDF), pp. 15 and 20.
What if I don't pass? For the state-licensure route, you must wait at least 30 days after a failed attempt; your board may require longer, and its approval window must still be valid. Each retake needs a new registration and fee. See the state-licensure handbook (PDF), pp. 10 and 24.
NCMHCE or NCE? Your state board decides which exam it accepts for licensure; check NBCC's State Board Directory.
When you're ready to book, our guide to NBCC exam registration walks through the steps. After test day, NBCC exam results explains how to find and read your official score.
Sources
Exam format and versions
- NBCC, NCMHCE examination page
- NBCC, NCMHCE Content Outline (PDF), revised Oct. 8, 2025
- NBCC, NCMHCE Candidate Handbook for State Licensure (PDF), revised Nov. 20, 2025
- NBCC, NCMHCE Examination Specifications, effective July 1, 2027 (PDF)
- NBCC, NCMHCE sample case study (PDF), updated March 2023
Ethics
- American Counseling Association, 2014 ACA Code of Ethics (PDF) (ACA identifies the 2014 Code as current while a revision is in progress)
- HHS, Creating a telehealth emergency plan
- HHS, Licensing across state lines, Cross-state licensure and Temporary practice laws
Assessment and diagnosis
- American Psychiatric Association, Prolonged Grief Disorder, diagnosis and symptom requirements
- NIMH, Bipolar Disorder and Depression, diagnostic assessment
- VA National Center for PTSD, PTSD and DSM-5
- VA National Center for PTSD, PTSD Checklist for DSM-5 (PCL-5)
- NIAAA, Understanding Alcohol Use Disorder
- NIH/NLM MedlinePlus, Alzheimer's Disease, symptoms, medical evaluation, and other causes
- NIAAA, Screen and Assess: Use Quick, Effective Methods, screening and diagnostic follow-up
- NIMH, Adult Outpatient Brief Suicide Safety Assessment Guide, assessment and safety planning
Interventions
- VA National Center for PTSD, Overview of Psychotherapy for PTSD and Prolonged Exposure (PE) for PTSD
- SAMHSA, Enhancing Motivation for Change in Substance Use Disorder Treatment, updated 2019: Chapter 1, Chapter 3, and Chapter 7
- NIAAA, Conduct a Brief Intervention: Build Motivation and a Plan for Change
- VA, Anger and Trauma; Grief: Helping Someone Else After a Loss; Grief: Different Reactions and Timelines
- Stanley-Brown Safety Planning Intervention, Steps to the Stanley-Brown Safety Plan
- VA/DoD, Safety Plan Worksheet (PDF) and Lethal Means Safety Counseling: Recommendations for Providers (PDF), updated December 2024
Exam format, blueprint dates, and linked sources last verified November 4, 2026. How Castleport checks sources.
This page was prepared with AI assistance. Source and editorial checks do not establish qualified clinical review or psychometric validation.
Castleport Test Prep Editorial Team. Castleport Test Prep is an independent exam prep publisher and is not affiliated with, endorsed by, or approved by the National Board for Certified Counselors (NBCC). The case studies and questions on this page are original, unofficial practice, not actual or recalled exam content. Exam and credential names identify their subjects; trademarks belong to their respective owners.