37a-521 Supervisory Plan - Board Of Behavioral Sciences
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1STATE 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
SUPERVISORY PLAN
Title 16, California Code of Regulations (CCR) Sections 1870.1 and 1822 require all associate clinical social workers and professional clinical
counselor interns and licensed mental health professionals acceptable to the Board as defined in Business and Professions Code Section
4996.23(a), 4999.12(h) ,and CCR Section 1874, who assume responsibility for providing supervision to those working toward a license as a
Clinical Social Worker or Professional Clinical Counselor to complete and sign the following supervisory plan. The original signed plan shall be
submitted by the registrant to the board upon application for examination eligibility.
REGISTRANT: (Please type or print clearly in ink.)
Legal name:
First
Middle
Registration Number
Last
Address
Number and Street
:
City
State
Zip Code
Business Telephone
Residence Telephone
(
)
(
)
LICENSED SUPERVISOR: (Please type or print clearly in ink.)
Name:
Last
First
Middle
License No:
Expiration Date:
Employer Name:
Telephone Number:
(
)
Address
Number and Street
:
City
State
Zip Code
Employment Setting:
d.
a. Private Practice
Licensed Health Facility
a.
e.
Governmental Entity
Social Rehabilitation Facility/Community Treatment Facility
b.
f.
Nonprofit and Charitable Corporation
Pediatric Day Health and Respite Care Facility
c.
g.
School, College, or University
Licensed Alcoholism or Drug Abuse Recovery or Treatment Facility
h.
Community Mental Health Facility
Briefly describe the goals and objectives:
I certify that I understand the responsibilities regarding clinical supervision, including the supervisor’s responsibility to
perform ongoing assessments of the supervisee, and I declare under penalty of perjury under the laws of the State of
California that the information submitted on this form is true and correct.
Supervisor’s Signature
Date signed
Registrant’s Signature
Date signed
The original of this form must be submitted to the board upon application for examination eligibility.
37A-521 (Rev.3/10)
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