37A 301A Form PDF Details

Navigating the path to becoming a Licensed Marriage and Family Therapist in California involves a detailed procedural framework, one critical component of which is the completion and submission of the 37A 301A form. Mandated by the State of California's Business, Consumer Services, and Housing Agency, under the governance of Governor Edmund G. Brown Jr., this form, endorsed by the Board of Behavioral Sciences, plays a pivotal role in the licensure process. Situated at the heart of Sacramento, the Board sets forth a mandatory requirement for applicants to report their in-state experience through a "New Streamlined Method" highlighted within this document. The 37A 301A form, tailored specifically to encapsulate the applicant's supervised hours of work pre and post-degree, underlines the significance of detailed, honest reporting across various employment settings and supervisors. To ensure a seamless verification process, it demands precise information about the applicant, including the supervisor and employment details, with a strict adherence to providing original signatures and rigorously checking the authenticity of the details provided. Additionally, it seeks to ascertain whether the experience was gained in a legally compliant environment conducive to mental health counseling or psychotherapy, underlining the nature of the employment whether paid or voluntary, and ensuring the experience aligns with the Board's stringent requirements. The form is designed not merely as a bureaucratic step but as a crucial phase in affirming the applicant's readiness and qualification for assuming the professional role of a Marriage and Family Therapist in California.

QuestionAnswer
Form Name37A 301A Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesbbs experience verification, experience verification 37a, form therapist verification, bbs verification

Form Preview Example

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

www.bbs.ca.gov

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.

•Use this “Option 1” form to report hours under the NEW streamlined method

•Use separate forms for pre-degree and post-degree experience

•Use separate forms for each supervisor and each employment setting

•Ensure that the form is complete and correct prior to signing

•Provide an original signature and have the supervisor initial any changes

•Do not submit Weekly Summary forms unless specifically requested

The hours reported on this form were earned (mark one):

Pre-Degree

Post-Degree

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? D N/A D No D Yes: Date Certified: __________ Cert. #: ____________

•LPCCs: Did you meet the qualifications to treat couples and families during the entire period of supervision, as

specified in California law? D N/A D No D Yes: Date you met the qualifications: ______________

APPLICANT’S EMPLOYER INFORMATION:

Name of Applicant’s Employer

Business Phone

Address

Number and Street

City

State

Zip Code

37A-301 (Revised 04/2017)

1 of 2

Applicant: Last

First

Middle

EMPLOYER INFORMATION (continued):

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

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

3.Was this experience gained in a setting that provided oversight to ensure that the 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?

If YES, attach a copy of the applicant’s W-2 statement for each year experience is claimed. If a W-2 has not yet been issued for this year, attach a copy of the current paystub. If applicant volunteered, submit a letter from the employer verifying volunteer status.

D Yes D No

D Yes D No D Yes D No

D Yes D No

D (preN/A-degree

experience)

EXPERIENCE INFORMATION:

 

1. Dates of experience being claimed:

 

From: __________________

To: _____________________

 

 

 

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 04/2017)

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How to Edit 37A 301A Form Online for Free

It's super easy to prepare the bbs experience verification. Our PDF editor was created to be assist you to prepare any form efficiently. These are the steps to follow:

Step 1: On this web page, hit the orange "Get form now" button.

Step 2: It's now possible to modify your bbs experience verification. This multifunctional toolbar will allow you to add, erase, adapt, and highlight content as well as carry out other sorts of commands.

Create the following parts to create the template:

portion of gaps in bbs form printable

Fill in the Supervisors Last Name, First, Middle, Business Phone, Email Address OPTIONAL, License Type, License Number, State, Date First Licensed, Physicians Were you certified in, entire period of supervision, D D No, Yes Date Certified Cert, LPCCs Did you meet the, and specified in California law fields with any information that is required by the system.

step 2 to finishing bbs form printable

You will be required to enter the details to let the software prepare the box Applicant, Last, First, Middle, EMPLOYER INFORMATION continued, Was this experience gained in a, Yes, health counseling or psychotherapy, Was this experience gained in a, Was this experience gained in a, For hours gained as an Intern, If YES attach a copy of the, Yes, Yes, and D D.

Applicant, Last, First, Middle, EMPLOYER INFORMATION continued, Was this experience gained in a, Yes, health counseling or psychotherapy, Was this experience gained in a, Was this experience gained in a, For hours gained as an Intern, If YES attach a copy of the, Yes, Yes, and D D in bbs form printable

For field EXPERIENCE INFORMATION, Dates of experience being claimed, From, mmddyyyy, To mmddyyyy, How many weeks of supervised, Hours of Experience, Logged Hours, a Total Direct Counseling, Of the above hours how many were, b Total NonClinical Experience, Supervision, Individual, Group group contained no more than, and Hours Per Week Logged Hours, indicate the rights and obligations.

Completing bbs form printable part 4

Finalize by reading these sections and filling them out correspondingly: NOTE Knowingly providing false, Signature of Supervisor, Date, and A Revised.

bbs form printable NOTE Knowingly providing false, Signature of Supervisor, Date, and A Revised fields to fill

Step 3: Click the "Done" button. Now it's possible to export your PDF document to your electronic device. As well as that, it is possible to deliver it via electronic mail.

Step 4: It is better to create copies of the file. You can rest assured that we won't distribute or view your particulars.

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