Bbs Form 37A 644 PDF Details

Entering the world of professional counseling in California requires a detailed and structured process for licensure, involving the accumulation and verification of supervised experience. One key component of this journey is the Board of Behavioral Sciences' 37A-644 form, a critical document designed only for Licensed Professional Clinical Counselors (LPCCs) pursuing licensure within the state. This form, established by the State of California and the State and Consumer Services Agency, is tasked with verifying in-state experience, demanding meticulous completion by both the applicant and their supervisor. Each supervisor is responsible for documenting the supervised hours in various categories, such as direct psychotherapy, group therapy, and even telephone counseling, ensuring the applicant meets the required experience threshold for licensure. Additional requirements include verification of employment status as an employee or volunteer, an overview of the settings where the experience was gained to confirm they align with regulatory definitions, and the specifics of face-to-face supervision provided. Moreover, the supervisor must detail their own licensure information, affirming their credentials. This procedural initiative underscores California's commitment to ensuring that aspiring LPCCs are adequately prepared, both theoretically and practically, underpinning the state’s dedication to maintaining high standards in mental health services.

Form NameBbs Form 37A 644
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesword bbs experience verification form, bbs experience verification form, bbs in state experience verification form fillable, bbs in state experience verification lpcc fillable form

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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



Applicant: Your supervisor must complete this form (unless experience is verified by an out-of-state licensing agency). Use a separate form for each person verifying hours of supervised experience toward licensure as a professional clinical counselor and for each employment setting. Submit this form with your application for examination eligibility.

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)












Social Security Number



























SUPERVISOR: (Please type or print clearly in ink)
























1. Supervisor:







2. Business Phone:


































3. Address:

Number and Street

















Zip Code






















4. Name of Applicant’s Employer:










5. Business Phone:
































6. Employer’s Address:

Number and Street

















Zip Code


















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

























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








































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














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?

























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?






































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

















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.




















Dates of the experience being claimed






















































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

























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










































Group Therapy or Group Counseling (maximum 500 hours)















































Telephone Counseling (maximum 250 hours)







































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













(maximum 250 hours)*







































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













(maximum 250 hours)*




















































Client Centered Advocacy (CCA)*









































37A-644 (New 6/11)















This form may be reproduced




13. Face-to-face supervision*:

Hours per week

Total Logged Hours







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





If M.D., were you certified in Psychiatry by the American Board of Psychiatry and Neurology during the entire period of 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:




*When combined, these categories shall not exceed 1,250 hours of experience (BPC Section 4999.46(b)(6)).

37A-644 (New 6/11)


This form may be reproduced

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Step 2: Now you can edit the bbs. You should use our multifunctional toolbar to include, remove, and adjust the content of the file.

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word bbs experience verification form gaps to fill out

Fill out the If the applicant was an employee, Yes, Dates of the experience being, From, mmddyyyy, mmddyyyy, How many weeks of supervised, Show only those hours of, maximum hours, e Workshops seminars training, maximum hours, f Client Centered Advocacy CCA, Total Logged Hours, A New, and This form may be reproduced space with all the information required by the program.

Filling in word bbs experience verification form part 2

You will have to provide certain information in the segment Applicant, Last, First, Middle, Facetoface supervision, a Individual, b Group Group supervision, Supervisor License Information, Hours per week Range, Total Logged Hours, Type of License, License Number, State of Licensure, Date Originally Licensed, and If MD were you certified in.

step 3 to finishing word bbs experience verification form

Inside of box Signature of Supervisor, Date, and When combined these categories, identify the rights and obligations.

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