On October 4, 2017, Bbs Form 37A 644 was filed with the Department of State. This document is an amendment to a previously-filed certification of formation for a limited liability company (LLC). The purpose of this amendment is to add an individual as a manager of the LLC. If you are considering adding an additional member/manager to your LLC, it is important to understand the implications of doing so. This blog post will provide some basic information about Bbs Form 37A 644 and what you need to know in order to make an informed decision about amending your LLC.
In the listing, there is some good information about the bbs form 37a 644. It is really worth making the effort to study this before you start filling in your document.
Question | Answer |
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Form Name | Bbs Form 37A 644 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | bbs experience verification form, word bbs experience verification form, bbs in state experience verification form fillable, board of behavioral sciences |
STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY |
Governor Edmund G. Brown Jr. |
Board of Behavioral Sciences
1625 North Market Blvd., Suite S200, Sacramento, CA 95834
Telephone: (916)
www.bbs.ca.gov
LICENSED PROFESSIONAL CLINICAL COUNSELOR
Applicant: Your supervisor must complete this form (unless experience is verified by an
Supervisor: You must complete this form. Make certain that this form is complete and correct prior to signing. Any change should be initialed by you and is subject to verification. Return the completed form to the applicant.
(Please type or print clearly in ink)
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Applicant: |
Last |
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Social Security Number |
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SUPERVISOR: (Please type or print clearly in ink) |
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1. Supervisor: |
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2. Business Phone: |
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3. Address: |
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Zip Code |
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4. Name of Applicant’s Employer: |
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5. Business Phone: |
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6. Employer’s Address: |
Number and Street |
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7. |
a. |
Was this experience gained in a setting that lawfully and regularly provides mental health counseling or psychotherapy? |
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Yes |
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No |
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b. Was this experience gained in a private practice setting? |
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Yes |
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No |
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c. Was this experience gained in a hospital or community mental health setting, as defined under California Code of Regulations |
Yes |
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No |
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section 1820(d) as a setting that: lawfully and regularly provides mental health counseling or psychotherapy; where clients |
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who routinely receive psychopharmacological interventions in conjunction with psychotherapy, counseling, or |
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interventions; where clients receive coordinated care that includes the collaboration of mental health providers; and is not a |
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private practice owned by a licensed professional clinical counselor, marriage and family therapist, a licensed psychologist, a |
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licensed clinical social worker, a licensed physician or surgeon, a professional corporation of any of these licensed professions |
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or unlicensed individuals? |
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8. |
Was this experience gained in a setting that provided oversight to ensure that the applicant’s work meets the experience and |
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supervision requirements and is within the scope of practice for the profession? |
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Yes |
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No |
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9. |
Was the applicant either an employee or a volunteer during the dates of experience claimed? |
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If the applicant was an employee and receiving pay, attach a copy of the applicant’s |
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Yes |
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No |
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experience is claimed. For the current year in which a |
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If applicant volunteered, a letter from the employer verifying volunteer status is required. |
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10. |
Dates of the experience being claimed |
From: |
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To: |
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mm/dd/yyyy |
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mm/dd/yyyy |
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11. How many weeks of supervised experience are being claimed? |
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12. Show only those hours of experience as logged on the weekly summary of hours form. |
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Total Logged Hours |
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a. |
Direct Psychotherapy (performed by the applicant; minimum 1,750 hours) |
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b. |
Group Therapy or Group Counseling (maximum 500 hours) |
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c. |
Telephone Counseling (maximum 250 hours) |
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d. |
Administering and evaluating psychological tests of counselees, writing clinical reports and progress or process notes |
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(maximum 250 hours)* |
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e. |
Workshops, seminars, training sessions, or conferences directly related to professional clinical counseling |
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(maximum 250 hours)* |
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f. |
Client Centered Advocacy (CCA)* |
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1 |
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This form may be reproduced |
Applicant:Last
First
Middle
13. |
Hours per week |
Total Logged Hours |
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(Range) |
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a.Individual
b.Group (Group supervision contained no more than eight (8) persons)
14.Supervisor License Information:
Type of License |
License Number |
State of Licensure |
Date Originally Licensed |
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If M.D., were you certified in Psychiatry by the American Board of Psychiatry and Neurology during the entire period of supervision?
Yes |
No |
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: |
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Date: |
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*When combined, these categories shall not exceed 1,250 hours of experience (BPC Section 4999.46(b)(6)).
2 |
This form may be reproduced |