Form Experience Verification Details

Did you know that the 37A 301A form is used to notify the IRS of a sale or exchange of property? If you're not familiar with this form, don't worry! In this blog post, we'll go over everything you need to know about the 37A 301A form. We'll also provide some tips on how to complete the form correctly.

In order to look at a few specific details when it comes to the file you are going to use, here is the data you can read before submitting the 37a 301a form.

QuestionAnswer
Form Name37A 301A Form
Form Length2 pages
Fillable?Yes
Fillable fields57
Avg. time to fill out11 min 58 sec
Other namesform therapist verification, bbs form fillable, ca bbs form experience, experience verification 37a

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

MARRIAGE AND FAMILY THERAPIST

EXPERIENCE VERIFICATION

FOR HOURS GAINED ON OR AFTER JANUARY 1, 2010

This form is to be completed by the applicant’s supervisor and submitted by the applicant with his or her Application for Examination Eligibility. All information on this form is subject to verification.

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

Use separate forms for each supervisor and each employment setting

Make sure that the form is complete and correct prior to signing

Provide an original signature in ink and have the signer initial any changes

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

Pre-Degree

Post-Degree

APPLICANT NAME:

Last

First

Middle

Intern Number

SUPERVISOR INFORMATION:

Supervisor’s Last Name

First

Middle

Address:

Number and Street

City

State

Zip Code

Business Phone

License Type

License Number

State

Date First Licensed

If a Physician, were you certified in Psychiatry by the American Board of Psychiatry and Neurology during the entire period of

supervision?

N/A

No

Yes: Date Board Certified: _______________ Certification #: _________________

If a LPCC, did you meet the qualifications to treat couples and families during the entire period of supervision, as specified in

California law?

N/A

No

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

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?

Yes

Yes

Yes

No

No

No

37A-301a (Revised 06/2015)

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Applicant: Last

First

Middle

EMPLOYER INFORMATION (continued):

4.For hours gained as an Intern ONLY: Was the applicant receiving pay for the employment?

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, a letter from the employer verifying volunteer status must be submitted.

Yes

No

N/A (pre-degree experience)

EXPERIENCE INFORMATION:

1. Dates of experience being claimed:

From: _____________________

mm/dd/yyyy

To: _______________________

mm/dd/yyyy

2.

How many weeks of supervised experience are being claimed? __________ weeks

 

 

 

 

 

 

3.

Show only those hours of experience logged on the Weekly Summary of Hours of Experience form*:

 

Logged Hours

 

 

 

 

 

 

a.

Individual Psychotherapy (No minimum or maximum hours required)

 

 

 

 

 

 

 

 

b.

Couples, families, and children (minimum 500 hours**)

 

 

 

 

 

 

 

 

 

Of the hours recorded on line 3.b, how many actual hours were gained providing conjoint

 

 

 

 

couples and family therapy?

 

 

 

 

 

 

c.Group Therapy or Counseling (maximum 500 hours)

d.Telehealth Counseling (maximum 375 hours)

e.Workshops, seminars, training sessions, or conferences directly related to marriage, family, and child counseling*** (maximum 250 hours)

For “f” and “g” below, list the number of hours earned during the time frames indicated:

2010 &

2012 &

2011

Later

 

f.Administering and evaluating psychological tests of counselees, writing clinical reports and progress or process notes

g.Client-Centered Advocacy

4. Face-to-face supervision***:

Units per week****

Logged Hours

a.Individual

b.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: _________________________

*Do not submit your Weekly Summary forms unless specifically requested by the Board

**Up to 150 hours treating couples and families may be double-counted toward the 500 total required

***These categories when combined with credited Personal Psychotherapy shall not exceed 1,000 hours of experience

****One “unit” of supervision is defined as one hour of individual supervision or two hours of group supervision. Do not provide an average - if your supervision hours differed from week to week, provide a range (for example, 2-3 units per week).

37A-301a (Revised 06/2015)

2 of 2

How to Edit 37A 301A Form

There isn't anything complex concerning filling in the 37a if you use our PDF editor. By following these clear steps, you can receive the fully filled out file within the least time period you can.

Step 1: Select the orange "Get Form Now" button on the following page.

Step 2: As soon as you've entered the editing page 37a, you should be able to notice each of the options intended for your file at the top menu.

The PDF form you are going to fill out will consist of the next areas:

part 1 to completing bbs verification form

Put the necessary information in the If a Physician, supervision, N/A, Yes: Date Board Certified:, If a LPCC, California law, N/A, Yes: Date you met the, APPLICANT’S EMPLOYER INFORMATION:, Name of Applicant’s Employer, Business Phone, Address, Number and Street, City, State, Zip Code, Yes, and psychotherapy area.

Filling out bbs verification form step 2

The system will demand for additional info to be able to instantly fill out the area Applicant:, Last, First, Middle, EMPLOYER INFORMATION (continued):, If YES, Yes, N/A (pre-degree experience), EXPERIENCE INFORMATION:, From: _____________________, To: _______________________, mm/dd/yyyy, and mm/dd/yyyy.

Completing bbs verification form step 3

The Logged Hours, Individual Psychotherapy (No, • Of the hours recorded on line, couples and family therapy, child counseling*** (maximum 250, For “f” and “g” below, 2012 & Later, progress or process notes, Units per week****, and Logged Hours box can be used to indicate the rights and responsibilities of both sides.

bbs verification form Logged Hours, Individual Psychotherapy (No, • Of the hours recorded on line, couples and family therapy, child counseling*** (maximum 250, For “f” and “g” below, 2012 & Later, progress or process notes, Units per week****, and Logged Hours fields to fill out

Finish the document by analyzing the following sections: Units per week****, NOTE: Knowingly providing false, Signature of Supervisor:, *Do not submit your Weekly Summary, **Up to 150 hours treating couples, ***These categories when combined, and ****One “unit” of supervision is.

stage 5 to filling out bbs verification form

Step 3: After you choose the Done button, your ready form can be exported to all of your devices or to electronic mail chosen by you.

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