Looking for a Bbs Forms And Templates? Download it for free!

Applicant:

Last

First

Middle

EMPLOYER INFORMATION (continued):

1. Was this experience gained in a setting that lawfully and regularly provides mental health

Yes

counseling or psychotherapy?

2. Was this experience gained in a private practice setting?

Yes

3. Was this experience gained in a setting that provided oversight to ensure that the applicant’s

Yes

work meets the experience and supervision requirements and is within the scope of practice?

4. For hours gained as an Intern ONLY: Was the applicant receiving pay?

Yes

If YES, attach a copy of the applicant’s W-2 statement for each year experience is claimed. If

N/A

a W-2 has not yet issued for this year, attach a copy of the current paystub. If applicant

(pre-degree

volunteered, submit a letter from the employer verifying volunteer status.

experience)

EXPERIENCE INFORMATION:

From: ___________________

To: _____________________

1. Dates of experience being claimed:

mm/dd/yyyy

2. How many weeks of supervised experience are being claimed? __________ weeks

3. Show only those hours of experience logged on the Weekly Summary of Hours of

Logged Hours

Experience form*:

a. Individual Psychotherapy (No minimum or maximum hours required)

b. Couples, families, and children (Minimum 500 hours**)

•

Of the hours recorded on line 3.b, how many actual hours were gained providing

conjoint couples and family therapy?

c. Group Therapy or Counseling (Maximum 500 hours)

d. Telehealth Counseling (Maximum 375 hours)

e. Workshops, seminars, training sessions, or conferences*** (Maximum 250 hours)

2010 &

2012 &

For “f” and “g” below, list the number of hours earned during the time frames indicated:

2011

Later

Administering and evaluating psychological tests of counselees, writing clinical reports

and progress or process notes

g. Client-Centered Advocacy

4. Face-to-face supervision***:

Hours Per Week

Logged Hours

a. Individual

b. Group (group contained no more than 8 persons)

NOTE: Knowingly providing false information or omitting pertinent information may be grounds for

denial of the application. The Board may take disciplinary action on a licensee who helps an

applicant obtain a license by fraud, deceit or misrepresentation.

Signature of Supervisor: __________________________________________ Date: _______________

* Do not submit your “Weekly Summary” forms unless specifically requested by the Board

** Up to 150 hours treating couples and families may be double-counted toward the 500 total required

*** These categories when combined with credited Personal Psychotherapy shall not exceed 1,000 hours

37A-302 (Revised 12/2015)

2 of 2

Licensed Marriage And Family Therapist In-State Experience Verification - Pre-Existing Multiple Category Method Page 2

Related Articles

Related forms

Related Categories