Licensed Marriage And Family Therapist In-State Experience Verification - Pre-Existing Multiple Category Method
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2STATE 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
LICENSED MARRIAGE AND FAMILY THERAPIST
IN-STATE EXPERIENCE VERIFICATION
OPTION 2 – PRE-EXISTING MULTIPLE CATEGORY METHOD
This form is to be completed by the applicant’s California supervisor and submitted by the applicant with his or her
Application for Licensure and Examination. All information on this form is subject to verification.
•
Use this “Option 2” form for reporting hours under the PRE-EXISTING method (multiple categories)
• Use separate forms for pre-degree and post-degree experience
• Use separate forms for each supervisor and each employment setting
The hours on this
•
Make sure that the form is complete and correct prior to signing
form were earned
•
(mark one):
Provide an original signature and have the supervisor initial any changes
Pre-Degree
• For your hours to qualify under “Option 2,” your Application for Licensure and
Post-Degree
Examination MUST be postmarked by December 31, 2020.
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
• Physicians: Were you certified in Psychiatry by the American Board of Psychiatry and Neurology during the
entire period of supervision?
N/A
No
Yes: Date Certified: __________ Cert. #: ____________
• LPCCs: 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
37A-302 (Revised 12/2015)
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