Article Guide
The 37A 301A form plays a crucial role in the licensure process for aspiring Licensed Marriage and Family Therapists (LMFTs) in California. This form is specifically designed for applicants to document their supervised experience, a vital requirement for obtaining licensure. By utilizing this streamlined method, applicants can report their hours under two distinct categories: pre-degree and post-degree experience. Each applicant must ensure that the form is meticulously completed and submitted alongside their Application for Licensure and Examination. It is essential for supervisors to provide accurate information, including their qualifications and the nature of the applicant's experience. The form also includes important sections that require verification of the employment setting, whether it lawfully provides mental health counseling or psychotherapy. Additionally, applicants must indicate if they received compensation for their work, which necessitates the inclusion of W-2 forms or pay stubs if applicable. The significance of this form cannot be understated; it not only serves as a record of the applicant's qualifications but also upholds the integrity of the licensing process by ensuring that all reported information is accurate and complete.
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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)
www.bbs.ca.gov
LICENSED MARRIAGE AND FAMILY THERAPIST
OPTION 1 – NEW STREAMLINED 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 1” form to report hours under the NEW streamlined method
•Use separate forms for
•Use separate forms for each supervisor and each employment setting
•Ensure that the form is complete and correct prior to signing
•Provide an original signature and have the supervisor initial any changes
•Do not submit Weekly Summary forms unless specifically requested
The hours reported on this form were earned (mark one):
APPLICANT NAME:
Last
First
Middle
Intern Number
IMF
SUPERVISOR INFORMATION:
Supervisor’s Last Name
First
Middle
Business Phone
Email Address (OPTIONAL)
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? D N/A D No D 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? D N/A D No D 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
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Applicant: Last
First
Middle
EMPLOYER INFORMATION (continued):
1.Was this experience gained in a setting that lawfully and regularly provides mental health counseling or psychotherapy?
2.Was this experience gained in a private practice setting?
3.Was this experience 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?
4.For hours gained as an Intern ONLY: Was the applicant receiving pay?
If YES, attach a copy of the applicant’s
D Yes D No
D Yes D No D Yes D No
D Yes D No
D
experience)
EXPERIENCE INFORMATION:
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1. Dates of experience being claimed: |
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From: __________________ |
To: _____________________ |
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mm/dd/yyyy |
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mm/dd/yyyy |
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2. How many weeks of supervised experience are being claimed? __________ weeks |
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3. Hours of Experience: |
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Logged Hours |
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a. Total Direct Counseling Experience |
(Minimum 1,750 hours) |
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• Of the above hours, how many were gained diagnosing and treating |
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Couples, Families and Children? (Minimum 500 of the 1,750 hours) |
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b. Total |
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• Of the above hours, how many were |
Hours Per Week |
Logged Hours |
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Supervision? |
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Individual |
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Group (group contained no more than 8 persons) |
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NOTE: Knowingly providing false information or omitting pertinent information may be grounds for denial of the application. The Board may take disciplinary action on a licensee who helps an applicant obtain a license by fraud, deceit or misrepresentation.
Signature of Supervisor: _______________________________________ |
Date: ______________ |
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Form Specifications
| Fact Name | Details |
|---|---|
| Form Purpose | This form verifies the in-state experience of applicants for the Licensed Marriage and Family Therapist (LMFT) license in California. |
| Governing Law | The form is governed by California Business and Professions Code, Section 4980.03. |
| Submission Requirement | The completed form must be submitted by the applicant along with their Application for Licensure and Examination. |
| Experience Reporting | Applicants must use separate forms for pre-degree and post-degree experience, as well as for each supervisor and employment setting. |
| Signature Requirement | The supervisor must provide an original signature and initial any changes made to the form. |
| Hours Tracking | Applicants must report a minimum of 1,750 hours of direct counseling experience, including at least 500 hours with couples, families, and children. |
| False Information Consequences | Providing false information or omitting details can lead to application denial and disciplinary action against the licensee. |
37A 301A: Usage Guidelines
Filling out the 37A 301A form requires careful attention to detail. This form must be completed by the applicant's California supervisor and submitted alongside the Application for Licensure and Examination. It is crucial to ensure that all information is accurate and complete before signing, as inaccuracies may lead to complications in the licensing process.
- Obtain the 37A 301A form from the California Board of Behavioral Sciences website or your supervisor.
- Identify whether the hours being reported are Pre-Degree or Post-Degree and mark the appropriate box.
- Fill in the applicant's name, including last name, first name, and middle name, along with the intern number.
- Provide the supervisor’s information, including last name, first name, middle name, business phone, and optional email address.
- Indicate the supervisor's license type, license number, state, and the date they were first licensed.
- For physicians, answer whether they were certified in Psychiatry during the entire supervision period and provide the certification date and number if applicable.
- For LPCCs, confirm if they met qualifications to treat couples and families during the supervision period and provide the date of qualification if applicable.
- Complete the applicant’s employer information, including the name of the employer, business phone, and address.
- Answer the questions regarding the experience setting, ensuring to mark Yes or No for each question.
- For intern experience, indicate whether the applicant received pay and attach the necessary documentation if applicable.
- Fill in the dates of experience being claimed, specifying the start and end dates in mm/dd/yyyy format.
- State the number of weeks of supervised experience being claimed.
- Log the total hours of experience, including direct counseling experience and non-clinical experience.
- Specify how many of the total hours were spent diagnosing and treating couples, families, and children.
- Document the hours of supervision, indicating both individual and group supervision hours.
- Sign the form and date it, ensuring that any changes are initialed by the supervisor.
Your Questions, Answered
What is the purpose of the 37A 301A form?
The 37A 301A form is used to verify the supervised experience of applicants seeking licensure as Marriage and Family Therapists in California. It must be completed by the applicant’s supervisor and submitted alongside the application for licensure and examination.
Who needs to complete the 37A 301A form?
The form must be completed by the applicant’s California supervisor. This supervisor should have directly overseen the applicant’s clinical experience during their training period.
What information is required on the form?
The form requires details about the applicant, the supervisor, and the employment setting. It includes sections for verifying the type of experience (pre-degree or post-degree), the hours logged, and specific qualifications related to the supervisor's credentials.
Can I submit this form if I have multiple supervisors?
If you have had multiple supervisors, you must submit separate forms for each supervisor. Each form should reflect the specific experience gained under that supervisor's oversight.
What should I do if I made a mistake on the form?
If there are any errors on the form, the supervisor must initial the corrections. Ensure that the form is complete and accurate before submission to avoid delays in the application process.
Is there a requirement for the number of hours logged?
Yes, there are minimum requirements. Applicants must log at least 1,750 hours of direct counseling experience, with a minimum of 500 hours specifically diagnosing and treating couples, families, and children. Non-clinical experience is also limited to a maximum of 1,250 hours.
What happens if I provide false information on the form?
Providing false information or omitting relevant details may lead to denial of your application. The Board may also take disciplinary action against any licensee who assists an applicant in obtaining a license through fraud or misrepresentation.
Do I need to submit any additional documentation with the form?
If the applicant received pay during their internship, a W-2 statement or current paystub should be attached. If the applicant volunteered, a verification letter from the employer is required. Ensure all necessary documents are included to support your application.
Common mistakes
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Incomplete Information: Many applicants fail to provide all required details on the form. Missing information can lead to delays or rejection of the application.
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Incorrect Signature: Some individuals overlook the importance of having the supervisor's original signature. A simple initial or electronic signature may not be accepted.
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Using the Wrong Form: Applicants sometimes use the wrong version of the form or do not separate pre-degree and post-degree experience. This mistake can complicate the verification process.
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Not Verifying Employment Settings: It is crucial to ensure that the experience was gained in a lawful setting that meets the requirements. Failing to confirm this can lead to issues during review.
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Omitting Required Attachments: Applicants often forget to include necessary documents, such as W-2 forms or letters verifying volunteer status. These attachments are essential for validating the reported experience.
Documents used along the form
When applying for licensure as a Marriage and Family Therapist in California, several forms and documents may accompany the 37A 301A form. Each of these documents serves a specific purpose in the application process, ensuring that all necessary information is collected and verified. Below is a list of commonly used forms and documents that applicants might need to submit.
- Application for Licensure and Examination: This is the primary document where applicants provide personal information, educational background, and details about their supervised experience. It serves as the official request for licensure.
- Weekly Summary Forms: These forms track the hours of supervised experience on a weekly basis. They are only submitted if specifically requested by the Board.
- W-2 Statements: If the applicant was paid during their internship, these tax documents must be included to verify employment and income for the claimed experience hours.
- Pay Stubs: For applicants who have not received a W-2 for the current year, recent pay stubs can serve as proof of employment and income.
- Verification of Volunteer Status: If the applicant volunteered during their experience, a letter from the employer confirming this status is required to validate the hours claimed.
- Supervisor’s License Verification: This document confirms that the supervisor holds a valid license and meets the qualifications to supervise the applicant's clinical experience.
- Experience Verification Forms: These forms provide detailed accounts of the applicant’s clinical experience, including settings and types of therapy provided.
- Transcripts: Official transcripts from educational institutions are needed to demonstrate that the applicant has completed the required coursework for licensure.
- Background Check Authorization: This document authorizes the Board to conduct a background check, which is a standard part of the licensure process.
Gathering these documents can seem overwhelming, but each one plays a crucial role in the application process. Ensuring that all forms are completed accurately and submitted in a timely manner can help streamline the journey toward becoming a licensed Marriage and Family Therapist in California.
Similar forms
The 37A 301A form is used in California for verifying the in-state experience of applicants for marriage and family therapist licensure. Several other documents serve similar purposes in various professional contexts. Below is a list of six documents that share similarities with the 37A 301A form.
- Experience Verification Form: This document is often required for various professional licenses. Like the 37A 301A form, it verifies the applicant's work experience under the supervision of a qualified professional.
- Internship Verification Form: Used by many fields, this form confirms that an intern has completed the necessary hours of supervised experience. It parallels the 37A 301A form in its focus on documenting supervised hours.
- Supervisory Agreement Form: This document outlines the terms of supervision between an applicant and their supervisor. Similar to the 37A 301A form, it ensures that the supervision meets the requirements set by the licensing board.
- Clinical Training Verification Form: This form is utilized in healthcare professions to verify clinical training hours. It serves a purpose akin to the 37A 301A form by documenting direct patient care hours.
- Postgraduate Supervision Form: Common in mental health fields, this form verifies the completion of postgraduate supervision hours. It shares the objective of the 37A 301A form in confirming experience under qualified supervision.
- Professional Experience Log: This document records the professional activities and hours worked by an applicant. Like the 37A 301A form, it is essential for demonstrating compliance with experience requirements for licensure.
Dos and Don'ts
When filling out the 37A 301A form, it is essential to follow specific guidelines to ensure a smooth application process. Below is a list of important do's and don'ts.
- Do use the correct form for reporting hours under the new streamlined method.
- Do complete separate forms for pre-degree and post-degree experience.
- Do ensure that the form is filled out completely and accurately before signing.
- Do provide an original signature and have the supervisor initial any changes made to the form.
- Do submit the form with your Application for Licensure and Examination.
- Don't submit Weekly Summary forms unless specifically requested.
- Don't forget to indicate whether the hours reported were pre-degree or post-degree.
- Don't leave any sections of the form blank; all information is subject to verification.
- Don't provide false information or omit any pertinent details, as this may result in denial of your application.
Misconceptions
Understanding the 37A 301A form is essential for applicants seeking licensure as Marriage and Family Therapists in California. However, several misconceptions exist about this form. Below is a list of common misunderstandings.
- All experience can be reported on one form. Each supervisor and employment setting requires a separate form.
- Only post-degree hours are valid. The form can report both pre-degree and post-degree experience, but separate forms must be used.
- Weekly Summary forms are always required. These forms should only be submitted if specifically requested.
- Any supervisor can sign the form. The supervisor must be a licensed professional who meets specific qualifications under California law.
- Experience does not need to be verified. All information on the form is subject to verification by the Board of Behavioral Sciences.
- Experience in any setting counts. The experience must be gained in a setting that lawfully provides mental health counseling or psychotherapy.
- Supervision is optional. The applicant's work must be supervised to ensure it meets experience and supervision requirements.
- Pay is not a factor in reporting experience. If the applicant was paid, a W-2 or paystub must be attached to verify the employment.
- There is no minimum hour requirement. A minimum of 1,750 hours of direct counseling experience is required, with specific hours dedicated to couples, families, and children.
- Submitting false information has no consequences. Knowingly providing false information may lead to application denial or disciplinary action against the licensee.
Addressing these misconceptions can help streamline the application process and ensure compliance with California regulations.
Key takeaways
Filling out and using the 37A 301A form is a critical step for applicants seeking licensure as a Marriage and Family Therapist in California. Below are key takeaways to consider:
- This form must be completed by the applicant's California supervisor and submitted alongside the Application for Licensure and Examination.
- It is essential to use this form for reporting hours under the new streamlined method, referred to as "Option 1."
- Separate forms are required for pre-degree and post-degree experience, as well as for each supervisor and employment setting.
- Before signing, ensure that the form is complete and correct to avoid delays in processing.
- Obtain an original signature from the supervisor, and have them initial any changes made to the form.
- Do not submit Weekly Summary forms unless specifically requested by the Board.
- Applicants must accurately report the hours earned, distinguishing between pre-degree and post-degree experiences.
- Be aware that providing false information or omitting important details may lead to application denial or disciplinary action.