Bbs - Marriage And Family Therapist Trainee / Intern Weekly Summary Of Experience Hours Option 2

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STATE 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
MARRIAGE AND FAMILY THERAPIST TRAINEE / INTERN
WEEKLY SUMMARY OF EXPERIENCE HOURS
OPTION 2 – PRE-EXISTING MULTIPLE CATEGORY METHOD
Use a separate log for each setting. For hours to qualify under Option 2, your Application for Licensure
and Examination MUST be postmarked by December 31, 2020.
Name of Trainee/Intern: Last
First
Middle
Supervisor Name
Date enrolled in graduate degree program
Name of Work Setting
Address of Work Setting
Indicate your status when the hours below are logged:
Trainee
Trainee in Practicum
Post-Degree / Intern Application Pending - BBS File No (if known): ________________
Registered Intern - MFT Intern Number: _______________
TOTAL
YEAR _________
WEEK OF:
HOURS
A. Individual Psychotherapy*
B. Diagnosis / Treatment of Couples,
Families, Children
B1. Conjoint Couple/Family Therapy**
C. Group Therapy
D. Telehealth Counseling
E. Workshops, Seminars, Training or
Conferences
F. Psych Testing, Report Writing,
Progress/Process Notes
G. Client Centered Advocacy
H. Supervision, Individual
I. Supervision, Group
TOTAL HOURS PER WEEK
* Performed by you
** B1 is a sub-category of “B.” When totaling weekly hours do not include the sub-category.
37A-527 (New 01/2016)

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