Bbs Form 37A 644 – Fill Out and Use This PDF

STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY

Governor Edmund G. Brown Jr.

Applicant:

Last

First

Middle

Social Security Number

SUPERVISOR: (Please type or print clearly in ink)

1. Supervisor:

Last

First

Middle

2. Business Phone:

3. Address:

Number and Street

City

State

Zip Code

4. Name of Applicant’s Employer:

5. Business Phone:

6. Employer’s Address:

Number and Street

City

State

Zip Code

7.

a.

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

Yes

No

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

Yes

No

c. Was this experience gained in a hospital or community mental health setting, as defined under California Code of Regulations

Yes

No

section 1820(d) as a setting that: lawfully and regularly provides mental health counseling or psychotherapy; where clients

who routinely receive psychopharmacological interventions in conjunction with psychotherapy, counseling, or psycho-social

interventions; where clients receive coordinated care that includes the collaboration of mental health providers; and is not a

private practice owned by a licensed professional clinical counselor, marriage and family therapist, a licensed psychologist, a

licensed clinical social worker, a licensed physician or surgeon, a professional corporation of any of these licensed professions

or unlicensed individuals?

8.

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 for the profession?

Yes

No

9.

Was the applicant either an employee or a volunteer during the dates of experience claimed?

If the applicant was an employee and receiving pay, attach a copy of the applicant’s W-2 statement for each year

Yes

No

experience is claimed. For the current year in which a W-2 has not been issued, submit a copy of a current paystub.

If applicant volunteered, a letter from the employer verifying volunteer status is required.

10.

Dates of the experience being claimed

From:

To:

mm/dd/yyyy

mm/dd/yyyy

11. How many weeks of supervised experience are being claimed?

12. Show only those hours of experience as logged on the weekly summary of hours form.

Total Logged Hours

a.

Direct Psychotherapy (performed by the applicant; minimum 1,750 hours)

b.

Group Therapy or Group Counseling (maximum 500 hours)

c.

Telephone Counseling (maximum 250 hours)

d.

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

(maximum 250 hours)*

e.

Workshops, seminars, training sessions, or conferences directly related to professional clinical counseling

(maximum 250 hours)*

f.

Client Centered Advocacy (CCA)*

37A-644 (New 6/11)

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13. Face-to-face supervision*:

Hours per week

Total Logged Hours

(Range)

Type of License

License Number

State of Licensure

Date Originally Licensed

Yes

No

Signature of Supervisor:

Date:

37A-644 (New 6/11)

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This form may be reproduced