Experience Verification
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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
MARRIAGE AND FAMILY THERAPIST
EXPERIENCE VERIFICATION
FOR HOURS GAINED ON OR AFTER JANUARY 1, 2010
The supervisor must complete this form. Use a separate form for each person verifying hours of supervised experience for licensure as a marriage and family
therapist and for each employment setting. Complete a separate form for pre-degree and post-degree hours. Make certain that the form is complete and
correct prior to signing. Any change should be initialed by the supervisor and is subject to verification. Experience verification forms are to be
submitted by the applicant with his or her application for examination eligibility.
(Please type or print clearly in ink)
Applicant:
Last
First
Middle
SUPERVISOR:
(Please type or print clearly in ink)
1. Supervisor Name:
Last
First
Middle
2. Business Phone:
3. Address:
City
State
Zip Code
Number and Street
4. Name of Applicant’s Employer:
5. Business Phone:
6. Employer’s Address:
City
State
Zip Code
Number and Street
Yes
No
7. a
Was this experience gained in a setting that lawfully and regularly provides mental health counseling or psychotherapy?
b. Was this experience gained in a private practice setting?
Yes
No
8
Experience was 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. For interns only , Was the applicant receiving pay for the employment? If yes, attach a copy of the applicant’s W-2
statement for each year experience is claimed. For the current year in which a W-2 has not been issued, submit a copy of a
current paystub.
Yes
No
If applicant volunteered, a letter from the employer verifying volunteer status is required.
10. Dates of the experience is 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 verified on the weekly summary of hours form.
Logged Hours
a.
(No minimum or maximum hours required)
Individual Psychotherapy
b.
Couples, families, and children (minimum 500 hours)
• Of the hours recorded on line 12. b., how many actual hours were gained via conjoint couples and family therapy.
c.
(maximum 500 hours)
Group Therapy or Counseling
d.
Telemedicine (maximum 375 hours)
e.
Administering and evaluating psychological tests of counselees, writing clinical reports and progress or process notes
(maximum 250 hours)
f.
Workshops, seminars, training sessions, or conferences directly related to marriage, family,
and child counseling* (maximum 250 hours)
g.
Client Centered Advocacy (CCA)*
Continue on next page.
37A-301a (Rev. 1/11)
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