Responsibility Statement For Supervisors Of A Marriage And Family Therapist Trainee Or Intern - Board Of Behavioral Sciences - State Of California
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2STATE 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
RESPONSIBILITY STATEMENT FOR SUPERVISORS
OF A MARRIAGE AND FAMILY THERAPIST TRAINEE OR INTERN
Title 16, California Code of Regulations (16 CCR) Section 1833.1 requires any qualified licensed mental health professional who assumes responsibility for
providing supervision to those working toward a Marriage and Family Therapist license to complete and sign, under penalty of perjury, the following statement
prior to the commencement of any counseling or supervision.
Name of MFT Trainee/Intern:
Last
First
Middle
Name of Qualified Supervisor:
Qualified Supervisor's Daytime Telephone Number:
As the supervisor:
1)
I am licensed in California and have been so licensed for at least two years prior to commencing this supervision.
(16 CCR § 1833.1(a)(1) and
Business and Professions Code (BPC) § 4999.12 (h))
A. The license I hold is:
Marriage and Family Therapist
License #
Issue Date
Licensed Clinical Social Worker
License #
Issue Date
Licensed Professional Clinical Counselor
License #
Issue Date
*Psychologist
License #
Issue Date
*Physician certified in psychiatry by the American Board of Psychiatry and
Neurology
License #
Issue Date
**B.
I have had sufficient experience, training, and education in marriage and family therapy to competently practice marriage and family
therapy in California.
(16 CCR § 1833.1(a)(2))
C.
I will keep myself informed about developments in marriage and family therapy and in California law governing the practice of
marriage and family therapy.
(16 CCR § 1833.1(a)(3))
2)
I have and maintain a current and valid license in good standing and will immediately notify any trainee or intern under my supervision of any
disciplinary action taken against my license, including revocation or suspension, even if stayed, probation terms, inactive license status, or
any lapse in licensure, that affects my ability or right to supervise.
(16 CCR § 1833.1(a)(1), (a)(4))
3)
I have practiced psychotherapy or provided direct supervision of trainees, interns, associate clinical social workers, or professional clinical
counselor interns who perform psychotherapy for at least two (2) years within the five (5) year period immediately preceding this supervision.
(16 CCR § 1833.1(a)(5))
4)
I have had sufficient experience, training, and education in the area of clinical supervision to competently supervise trainees or interns.
(16
CCR § 1833.1(a)(6))
5)
I have completed six (6) hours of supervision training or coursework within the renewal period immediately preceding this supervision, and
must complete such coursework in each renewal period while supervising. If I have not completed such training or coursework, I will
complete a minimum of six (6) hours of supervision training or coursework within sixty (60) days of the commencement of this supervision,
and in each renewal period while providing supervision.
(16 CCR § 1833.1(a)(6)(A)&(B))
6)
I know and understand the laws and regulations pertaining to both the supervision of trainees and interns and the experience required for
licensure as a marriage and family therapist.
(16 CCR § 1833.1(a)(7))
7)
I shall ensure that the extent, kind, and quality of counseling performed is consistent with the education, training, and experience of the
trainee or intern.
(16 CCR § 1833.1(a)(8))
37A-523 (Rev. 3/10)
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