Responsibility Statement For Supervisors Of A Marriage And Family Therapist Trainee Or Intern - Board Of Behavioral Sciences - State Of California Page 2
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28)
I shall monitor and evaluate the extent, kind, and quality of counseling performed by the trainee or intern by direct observation, review of
audio or video tapes of therapy, review of progress and process notes and other treatment records, or by any other means deemed
appropriate.
(16 CCR § 1833.1(a)(9))
9)
I shall address with the trainee or intern the manner in which emergencies will be handled.
(16 CCR § 1833.1(a)(10))
10)
I agree not to provide supervision to a TRAINEE unless the trainee is a volunteer or employed in a setting that meets all of the following: (A)
lawfully and regularly provides mental health counseling or psychotherapy; (B) provides oversight to ensure that the trainee’s work at the
setting meets the experience and supervision requirements and is within the scope of practice for the profession as defined in BPC Section
4980.02; (C) is not a private practice owned by a licensed marriage and family therapist, a licensed psychologist, a licensed clinical social
worker, a licensed physician and surgeon, or a professional corporation of any of those licensed professions.
(BPC § 4980.43(d)(1))
11)
I agree not to provide supervision to an INTERN unless the intern is a volunteer or employed in a setting that meets both of the following: (A)
lawfully and regularly provides mental health counseling or psychotherapy; (B) provides oversight to ensure that the intern’s work at the
setting meets the experience and supervision requirements and is within the scope of practice for the profession as defined in BPC Section
4980.02.
(BPC § 4980.43(e)(1))
12)
If I am to provide supervision on a voluntary basis in a setting which is not a private practice, a written agreement will be executed between
myself and the organization in which the employer acknowledges that they are aware of the licensing requirements that must be met by the
intern or trainee, they agree not to interfere with my legal and ethical obligations to ensure compliance with these requirements, and they
agree to provide me with access to clinical records of the clients counseled by the intern or trainee.
(16 CCR § 1833(b)(4))
13)
I shall give at least (1) one week's prior written notice to a trainee or intern of my intent not to sign for any further hours of experience for
such person. If I have not provided such notice, I shall sign for hours of experience obtained in good faith where I actually provided the
required supervision.
(16 CCR § 1833.1(c))
14)
I shall obtain from each trainee or intern for whom supervision will be provided, the name, address, and telephone number of the trainee’s
or intern’s most recent supervisor and employer.
(16 CCR § 1833.1(d))
15)
In any setting that is not a private practice, I shall evaluate the site(s) where a trainee or intern will be gaining hours of experience toward
licensure and shall determine that: (1) the site(s) provides experience which is within the scope of practice of a marriage and family therapist;
and (2) the experience is in compliance with the requirements set forth in 16 CCR Section 1833 and Section 4980.43 of the Code.
(16 CCR §
1833.1(e))
16)
Upon written request of the Board, I shall provide to the board any documentation which verifies my compliance with the requirements set
forth in 16 CCR Section 1833.1.
(16 CCR § 1833.1(f))
17)
I shall provide the intern or trainee with the original of this signed statement prior to the commencement of any counseling or
supervision.
(16 CCR § 1833.1(b))
I declare under penalty of perjury under the laws of the State of California that I have read and understand the foregoing and that I meet
all criteria stated herein and that the information submitted on this form is true and correct.
_______________________________________
_____________________________________________
_______________
Printed Name of Qualified Supervisor
Signature of Qualified Supervisor
Date
____________________________________________________________________________________________________________________________________________
Mailing Address: Number and Street
City
State
Zip Code
The supervisor shall provide the intern or trainee being supervised with the original of this signed statement prior to the commencement of any
counseling or supervision.
.
The trainee or intern shall submit this form to the board upon application for examination eligibility
* Psychologists and Physicians certified in psychiatry are not required to comply with #5.
** Applies only to supervisors NOT licensed as a Marriage and Family Therapist.
37A-523 (Rev. 3/10)
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