Bbs Form 37A 644 PDF Details

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.

QuestionAnswer
Form NameBbs Form 37A 644
Form Length2 pages
Fillable?Yes
Fillable fields58
Avg. time to fill out12 min 10 sec
Other namesbbs in state experience verification form, bbs experience verification form, word bbs experience verification form, bbs california

Form Preview Example

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) 574-7830 TTY: (800) 326-2297

www.bbs.ca.gov

LICENSED PROFESSIONAL CLINICAL COUNSELOR

IN-STATE EXPERIENCE VERIFICATION

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)

 

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)

 

 

1

 

 

 

 

 

 

 

 

 

 

 

This form may be reproduced

Applicant:Last

First

Middle

13. Face-to-face supervision*:

Hours per week

Total Logged Hours

 

 

(Range)

 

 

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

 

 

 

 

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:

 

Date:

 

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

37A-644 (New 6/11)

2

This form may be reproduced

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Fill out the If the applicant was an employee, From:, mm/dd/yyyy, To:, mm/dd/yyyy, Total Logged Hours, (maximum 250 hours)*, (maximum 250 hours)*, 37A-644 (New 6/11), and This form may be reproduced space with all the information required by the program.

Filling in bbs forms part 2

You will have to provide certain information in the segment Applicant:, Last, First, Middle, Hours per week, (Range), Total Logged Hours, Type of License, License Number, State of Licensure, Date Originally Licensed, If M, Date:, Yes, and *When combined.

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