Experience Verification Page 2
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2Applicant:
First
Middle
Last
13. Face-to-face supervision*:
Hours per week
Logged Hours
a. Individual
b. Group (Group supervision contained no more than 8 persons)
14. Supervisor License Information:
Type of License
License Number
State of License
Date Originally Licensed
If M.D., were you certified in Psychiatry by the American Board of Psychiatry and Neurology during the entire period of
Yes
No
supervision?
Date Board certified: _________________________
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct
Signature of Supervisor:
Date:
*
These categories when combined with credited Personal Psychotherapy shall not exceed 1250 hours of experience.
37A-301a (Rev. 1/11)
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