Licensed Marriage And Family Therapist In-State Experience Verification - New Streamlined Method Page 2

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Applicant:
Last
First
Middle
APPLICANT’S EMPLOYER INFORMATION:
Name of Applicant’s Employer
Business Phone
1. Was this experience gained in a setting that lawfully and regularly provides mental
Yes
No
health counseling or psychotherapy?
2. Was this experience gained in a private practice setting?
Yes
No
3. Was this experience gained in a setting that provided oversight to ensure that the
Yes
No
applicant’s 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
No
If YES, attach a copy of the applicant’s W-2 statement for each year experience
N/A
is claimed. If a W-2 has not yet been issued for this year, attach a copy of the
(pre-degree
current paystub. If applicant volunteered, submit a letter from the employer
experience)
verifying volunteer status.
EXPERIENCE INFORMATION:
From: __________________
To: _____________________
1. Dates of experience being claimed:
mm/dd/yyyy
mm/dd/yyyy
2. How many weeks of supervised experience are being claimed? __________ weeks
3. Hours of Experience:
Logged Hours
a. Total Direct Counseling Experience (Minimum 1,750 hours)
• Of the above hours, how many were gained diagnosing and treating
Couples, Families and Children? (Minimum 500 of the 1,750 hours)
b. Total Non-Clinical Experience (Maximum 1,250 hours)
• Of the above hours, how many were Face-to-Face
Hours Per Week Logged Hours
Supervision?
Individual
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: ______________
37A-301 (Revised 01/2017)
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