Licensed Marriage And Family Therapist In-State Experience Verification - New Streamlined Method

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STATE OF CALIFORNIA – BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY
Governor Edmund G. Brown Jr.
Board of Behavioral Sciences
1625 North Market Blvd., Suite S200, Sacramento, CA 95834
Telephone: (916) 574-7830
TTY: (800) 326-2297
LICENSED MARRIAGE AND FAMILY THERAPIST
IN-STATE EXPERIENCE VERIFICATION
OPTION 1 – NEW STREAMLINED METHOD
This form is to be completed by the applicant’s California supervisor and submitted by the applicant
with his or her Application for Licensure and Examination. All information on this form is subject to
verification.
The hours
• Use this “Option 1” form to report hours under the NEW streamlined method
reported on this
• Use separate forms for pre-degree and post-degree experience
form were earned
• Use separate forms for each supervisor and each employment setting
(mark one):
 Pre-Degree
• Ensure that the form is complete and correct prior to signing
 Post-Degree
• Provide an original signature and have the supervisor initial any changes
• Do not submit Weekly Summary forms unless specifically requested
APPLICANT NAME:
Last
First
Middle
Intern Number
IMF
SUPERVISOR INFORMATION:
Supervisor’s Last Name
First
Middle
Business Phone
Email Address (OPTIONAL)
License Type
License Number
State
Date First Licensed
• Physicians: Were you certified in Psychiatry by the American Board of Psychiatry and Neurology
during the entire period of supervision?
No
Yes: Date Board Certified: ______________
Certification Number: ______________
• LPCCs: Did you meet the qualifications to treat couples and families during the entire period of
supervision, as specified in California law?
No
Yes: Date you met the qualifications:
_______________
37A-301 (Revised 01/2017)
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