mft fieldwork packet...your weekly logs and experi-ence veriﬁcation forms are generated with one...

13 13 13

MS13 in13 Clinical13 Psychology13 13 13

Fieldwork13 Packet13 13 13 13

2017-shy‐1813 13

San Jose State University MS Clinical Psychology Program

Fieldwork Placement Contract

Instructions to student and placement coordinator This form should be completed in consultation after the SJSU student has received verbal site approval from the fieldwork coordinator Name _______________________________________ Phone ___________________ Address __________________________________________________________________ Agency Information Placement ___________________________________ Phone ___________________ Placement Address _________________________________________________________ Name of Supervisor ___________________________ Phone ___________________ Supervisor Credentials Degree _________ Date Degree Granted ________ Institution ______________________ License ________ Year Granted _________ Years of Supervisory Experience ________ Clinical Responsibilities and Training

1 Supervision Format(s) (Individual Group etc) ______________________________

2 _____ hour(s) of individual supervision each week per _____ client contact hours

3 Theoretical Orientation of the Supervisor ___________________________________ Clinical Responsibilities and Training

1 Clientele served by the agency ___________________________________________

2 Description of clinical problems trainee is likely to address _____________________

____________________________________________________________________ ____________________________________________________________________

Continued on other side



3 Total hours per week at placement _________

Individual Client load _________ clientsweek Group therapy __________ hoursweek Family Therapy __________ hoursweek Other therapy responsibilities (please describe) ____________________________________________________________________ ____________________________________________________________________

Administrative Responsibilities

1 TestingReport Writing (describe) ____________________________________________________________________ 2 Staff Meetings _______ hoursweek 3 Other Responsibilities (please describe) _________________________________ ____________________________________________________________________ 4 In-service or other training available to trainee ____________________________ ____________________________________________________________________

I understand that trainees at SJSU will not transport any clients in their car SIGNATURES MS Clinical Student _________________________________ Date _______________ Supervisor of Training ______________________________ Date _______________ Title of Supervisor _________________________________

Back to Top | Conditions of Use | Privacy Policy | Accessibility | Contact UsCopyright copy 2012 State of California

This web site contains PDF documents that require the most current version of Adobe Reader to view To download click on the icon below

Online License Registration Verification

NOTICE TO LICENSE VERIFICATION USERS

The Boards Breeze Online Service provides you with accurate up-to-date license verification information The licensing or registration information on the Boards websitecomes directly from the Boards licensing records The Board allows a screen print of the license or registration to be used for verification purposes

The following licenses and registrations are issued by Board of Behavioral SciencesRegistrant LicenseeAssociate Clinical Social Workers (ASW) Licensed Clinical Social Workers (LCSW)Marriage and Family Therapist Interns (IMF) Licensed Marriage and Family Therapists (LMFT)Professional Clinical Counselor Intern (PCCI) Licensed Professional Clinical Counselor (LPCC)Continuing Education Providers (PCE) Licensed Educational Psychologists (LEP)

STATEMENT REGARDING PRIMARY SOURCE DATA ON THE BOARD OF BEHAVIORAL SCIENCES WEB SITE

The California Board of Behavioral Sciences (BBS) has an intradepartmental contract with the Department of Consumer Affairs (DCA) to provide the license lookup Website and the actual operation thereof The license lookup Web site is the property of DCA and system security concerns are ultimately their responsibility The informationthat the BBS provides to DCA is a true and accurate reflection of our license records that are derived from primary source documents We are informed that while theDepartment believes the information to be reliable human or mechanical error remains a possibility as does delay in the posting or updating of information AccordinglyDCAs license lookup reflects the BBS primary source information The license lookup information is updated on a daily basis therefore the information is current as to thedate indicated on the site

Your organization is responsible for any decision it may make based on our Web site information However it is our intent to provide accurate licensee information and toallow users the ability to verify licenses

The Board also processes official certifications

LICENSE STATUS INFORMATION

Our License Status Definitions provide a description of the various license status a licensee or registrant may hold

If the license or registration verified has any pending or final disciplinary actions the information will be included The Board posts official documentation on citationsaccusations and disciplinary actions

Disciplinary actions taken by the Board become operative on the effective date except in situations where the licensee obtains a court-ordered stay This may occur afterthe publication of the information in this website

For updated information on stay orders and appeals or for further information on specific discipline for a person listed you may contact the Boards Enforcement Unit at(916) 574-7890

Contact Us | Verify a License | Accessibility

BOARD ACTIVITY CONSUMERS APPLICANTS LICENSEES FORMSPUBS

SearchThis Site California

Track Your Hours is up-to-date with the most cur-

rent BBS regulations and automatically applies

the appropriate rules based on the date your

hours were earned

Whether your hours were earned yesterday or sev-

en years ago Track Your Hours will apply the ap-

propriate rules and generate the correct forms

Enter your hours and you will instantly be able

to see how many you can actually claim You

can even log hours on your phone

Visual progress reports keep you on track Alerts

keep you informed Your weekly logs and experi-

ence verification forms are generated with one

click

Track Your Hours is currently available for Califor-

nia Trainees and Interns seeking licensure as an

MFT LCSW or LPCC We offer a 30-day free trial

with no credit card required

Why have over 15000 MFT Trainees amp Interns chosenTrack Your Hours

Free Trial

TrackYourHoursSimply the best way to track and reportyour professional training hours

Log In Free Trial

Supervision Ratios Monitored

Your supervision ratios are calculated across all su-

pervisors at each site and you receive an alert

whenever there is an issue The appropriate su-

pervision requirements are applied based on your

status as a Trainee or Intern

Category Multipliers Applied

Conjoint couples amp family and personal psy-

chotherapy multipliers are applied so you know

how many hours you can claim

Weeks of Supervision Tracked

Your weeks of supervision and individual supervi-

sion are tracked automatically Only weeks where

you meet the minimum requirement are counted

Summary Report

Your summary report provides an overview of your

progress toward meeting each of the licensure re-

quirements including category minimums and

weeks of supervision

13 MFT13 Specific13 Documents13

13

13

LMFT Education Requirements - Effective August 1 2012New LMFT education requirements take effect August 1 2012 and apply to the following individuals

Applicants for licensure or registration who began graduate study on or after August 1 2012Applicants who began graduate study before August 1 2012 and who graduated from a degree program that meets the requirements stipulated inBusiness and Professions Code Section 498036 orApplicants who began graduate study before August 1 2012 and did not complete that study on or before December 31 2018

Degree Program Requirements

The degree program must contain no less than 60 semester or 90 quarter units of instructionThe degree program does the following

1 Throughout its curriculum integrates marriage and family therapy principles the principles of mental health recovery-oriented care and methods of servicedelivery in recovery-oriented practice environments and an understanding of various cultures and the social and psychological implications ofsocioeconomic position and an understanding of how poverty and social stress impact an individuals mental health and recovery

2 Allows for innovation and individuality in the education of marriage and family therapists3 Encourages students to develop the personal qualities that are intimately related to effective practice4 Permits an emphasis or specialization that may address any one or more of the unique and complex array of human problems symptoms and needs of

Californians served by marriage and family therapists and5 Provides students with the opportunity to meet with various consumers and family members of consumers of mental health services to enhance

understanding of their experience of mental illness treatment and recovery

The degree program includes no less than 12 semester or 18 quarter units of coursework in theories principles and methods of a variety ofpsychotherapeutic orientations directly related to marriage and family therapy and marital and family symptoms approaches to treatment and howthese theories can be applied therapeutically with individuals couples families adults including elder adults children adolescents and groups toimprove restore or maintain healthy relationships as stipulated in BPC Section 498036(d)(1)(A)The degree program includes no less than six semester or nine quarter units of practicum that involves direct client contact in a supervised clinicalplacement that provides supervised fieldwork experience and adheres to the requirements stipulated in BPC Section 498036(d)(1)(B)(iv)The practicum in the degree program includes a minimum of 150 hours of face-to-face experience counseling individuals couples families orgroups (BPC Section 498036(d)(1)(B)(ii))In addition to the 150 hours of face-to-face experience the practicum must include 75 hours of either of the following

Client-centered advocacy as defined in Section 498003 orFace-to-face experience counseling individuals couples families or groups (BPC Section 498036(d)(1)(vi))

The degree program includes instruction in diagnosis assessment prognosis and treatment of mental disorders (Psychopathology) as specifiedin BPC Section 498036(d)(2)(A)The degree program includes instruction in developmental issues from infancy to old age and all areas of study specified in BPC Section498036(d)(2)(B)The degree program includes instruction in the broad range of matters and life events that may arise within marriage and family relationships andwithin a variety of California cultures and includes instruction in all areas of study specified in BPC Section 498036(d)(2)(C)The degree program includes instruction in cultural competency and sensitivity and the areas of study specified in BPC Section 498036(d)(2)(D)The degree program includes instruction in multicultural development cross-cultural interaction and the areas of study specified in BPC Section498036(d)(2)(E)The degree program includes instruction in the effects of socioeconomic status on treatment and available resources as specified in BPC Section498036(d)(2)(F)The degree program includes instruction in resilience and the areas of study specified in BPC Section 498036(d)(2)(G)The degree program includes instruction in human sexuality and the areas of study specified in BPC Section 498036(d)(2)(H)The degree program includes instruction in substance use disorders co-occurring disorders addiction and the areas of study specified in BPCSection 498036(d)(2)(I)The degree program includes instruction in California law and professional ethics for marriage and family therapists and the areas of studyspecified in BPC Section 498036(d)(2)(J)The degree program includes instruction in case management systems of care for the severely mentally ill public and private services andsupports available for the severely mentally ill community resources for persons with mental illness and for victims of abuse disaster and traumaresponse advocacy for the severely mentally ill and collaborative treatment as specified in BPC Section 498036(e)

Please refer to BPC Section 498036 for the exact education requirements effective August 1 2012

How Are the Education Requirements Changing August 1 2012

The main difference in the requirements that go into effect August 1 2012 is the separation of the additional coursework requirements such as human sexuality andpsychopharmacology The new requirements integrate these areas into the degree program requirements rather than treating them as separate courses that may becompleted outside of the degree program Applicants that fall under the requirements effective August 1 2012 must meet the qualifying degree program requirements inorder to be registered as an MFT Intern Under the previous requirements some of the additional coursework could be completed outside of the degree program and afterbeing issued an intern registration number

A list of schools with MFT programs is provided on the BBS Web site Please contact the school for more information on whether or not the degree meets the necessaryrequirements




BBS Requirements for Pre-Degree Hours for 2012 and After

From SJSU MS Clinical Student Handbook ldquoThe Board of Behavioral Sciences requires that students accrue a minimum of 150 hours of face-to-face counseling experience during the practicum experience (before graduation) a requirement that is typically met without difficulty in the normal course of the program In addition there are 75 required hours engaged in client centered advocacy or face-to-face experience counseling individuals couples families or groupsrdquo Note that the total is 225 hours 75 hours can be client centered advocacy (CCA) but the other 150 hours must be face-to-face hours (individuals couples families groups) If you have 225 hours face to face that is great If it is less you can fill it with CCA as long as you have the 150 hour minimum Note that as far as can be determined supervisors may sign off on CCA at their discretion This means they may or may not endorse these They MUST be signed off to hit the 225 hour pre-degree minimum to graduate It may be helpful to discuss the BBS definition of CCA and the requirement for pre-degree hours

From BBS

httpwwwbbscagovpdfpublicationsmft_sup-exp_changes_sb33_faqpdf

Client Centered Advocacy

What is client centered advocacy (CCA)

CCA is defined in Business and Professions Code (BPC) Section 498034(h) as including but not limited to ldquoresearching identifying and accessing resources or other activities related to obtaining or providing services and supports for clients or groups of clients receiving psychotherapy or counseling servicesrdquo

FAQrsquos for Weekly Summary of Hours of Experience

amp MFT Experience Verification Form

When completing these forms be sure to complete all necessary fields The Weekly Summary of Hours of Experience and the MFT Experience Verification form are the two forms used to document supervised work experience requirements

1 How do I logget credit for the conjoint couples and family incentive hours When completing the Weekly Summary of Hours of Experience form and the MFT Experience Verification form you will document the total couples families and children hours gained on or after 112010 on the form item titled ldquoCouples families and childrenrdquo In the subsection below record the amount of actual conjoint couples and families hours This subsection is only for recording purposes and will not affect your supervision requirements or increase your weekly totals Please only document actual hours Do not double count the hours on your forms Once your application is received by the Board those hours will be evaluated and up to the first 150 hours of conjoint couples and family hours will be double counted to a maximum of 300 hours For example If Allison completed 10 couples families and children hours and 6 of those hours were conjoint couples and family Allison would record 10 hours in the couples families and children category and 6 hours below in the conjoint couples and family subsection

2 If I have already gained conjoint couples and family hours before 112010 can I count those prior hours towards the incentive

No Only the first 150 hours of conjoint couples and family hours gained on or after 112010 will be double counted

3 How do I know when to stop using the old forms and start using the new forms For any hours gained on or after 112010 the Board of Behavioral Sciences (BBS) encourages all Trainees and Interns to start using the new Weekly Summary of Hours of Experience form and MFT Experience Verification form Any hours gained prior to 112010 should be documented on the previous versions of the forms The current version and prior version of the Weekly Summary of Hours of Experience and the MFT Experience Verification are available on the ldquoForms and Publicationsrdquo section of the BBS Web site (httpwwwbbscagovformsshtml)

4 Can I combine pre-degree and post-degree work experience on the same form The BBS advises separating pre- and post-degree experience on separate Weekly Summary of Hours of Experience and MFT Experience Verification forms As long as your application for Intern registration is submitted within 90 days of your degree conferral date you may count experience gained during this time and log these as post-degree hours If you do not submit your application within 90 days you will not be able to count hours until your Intern registration number is issued

5 Now that W-2s or a letter verifying volunteer status are required for MFT Interns do I have to locate all past employers when I was employed before 112010 to get documentation

No Only Interns must submit a W-2 or letter from the employer verifying voluntary status for hours gained on or after 112010 This is not required for any hours gained before this date or for Trainees

6 How do I fill out the forms if I have more than one supervisor in the same work setting

If you are receiving supervision from two individuals in an employment setting you can document this on separate forms As long as the time periods on the two forms overlap and the employment setting is the same the BBS will lump the experience and supervision together upon evaluation of the forms

7 As a Trainee can I count administering and evaluating psychological tests of counselees writing clinical reports and progress and process notes

Yes Starting 112010 Trainees can now count these hours up to the maximum of 250 hours Any hours gained as a Trainee in this category prior to 112010 will not be able to count

FREQUENTLY ASKED QUESTIONS

CLIENT-CENTERED ADVOCACY FOR LICENSED MARRIAGE AND FAMILY THERAPY (LMFT) APPLICANTS

1) How has the law changed regarding gaining hours of client-centered advocacy experience for LMFT applicants

The change in law limits the maximum amount of client centered advocacy that can be gained as experience for licensure to 500 hours

Below is a summary of how the law has changed

2) When does this law go into effect

The new law becomes effective on January 1 2012

New Law

Effective January 1 2012

1 No more than 1000 hours of experience in the following areas bull Direct Supervisor

Contact and bull Professional Enrichment

Activities

2 For hours gained on or after January 1 2012 no more than 500 hours of experience in the following areas bull Administeringevaluating

psychological tests bull Writing clinical reports

progress notes andor process notes and

bull Client centered advocacy

Previous Law


Contact bull Professional Enrichment

Activities and bull Client Centered Advocacy

2 No more than 250 hours of

experience in the following areas bull Administeringevaluating

psychological tests and bull Writing clinical reports

progress notes andor process notes

3) Why was this law passed

The law was passed due to concerns that applicants for LMFT licensure could potentially gain a large number of client centered advocacy hours to use toward the experience hours required for licensure However future clients as well as the public would be better protected if the applicants were gaining experience through a wider variety of training activities

4) Irsquom an LMFT applicant with more than 500 client centered advocacy hours What if I sent my application in to the Board before January 1 2012 but I am waiting for the Board to review my application

As long as the hours were gained prior to January 1 2012 the new requirements do not apply to you

5) I have more than 500 client centered advocacy hours What if I send in my application after January 1 2012

If the hours were gained prior to January 1 2012 then the requirements of the new law do not apply to you

6) I have 750 hours of client centered advocacy Of that amount 700 hours were gained prior to January 1 2012 and 50 hours were gained after January 1 2012 Can I count all of those hours

No The 700 hours gained prior to January 1 2012 would count However the 50 hours gained after January 1 2012 are above and beyond the 500 hours allowed under the new law and will not count

NEW OPTION FOR SUPERVISED EXPERIENCE CATEGORIES

AVAILABLE JANUARY 1 2016

FOR LMFT AND LPCC APPLICANTS

A new streamlined option for the categories of supervised experience that can be claimed will be available effective January 1 2016 for LMFT and LPCC applicants

Hours gained after January 1 2010 can now qualify under either Option 1 (new streamlined categories) or Option 2 (pre-existing categories) as described below Applicants must fully qualify under Option 1 OR Option 2 There is no ldquomixing and matchingrdquo between the two categories

Individuals who wish to qualify under Option 2 must submit an Application for Licensure and Examination postmarked no later than December 31 2020 Otherwise the applicant must qualify under Option 1

Per Senate Bill 620 Chapter 262 Statutes of 2015

LMFT OPTION 1 (new streamlined categories)

Under the new option the supervised work experience categories break down into just two overall types

bull Direct counseling experience (minimum 1750 hours) o A minimum of 500 of the above hours must be gained diagnosing and

treating couples families and children

bull Non-clinical experience (maximum 1250 hours) o May consist of direct supervisor contact administering and evaluating

psychological tests writing clinical reports writing progress or process notes client centered advocacy and workshops seminars training sessions or conferences

LMFT OPTION 2 (pre-existing multiple categories)

a Individual Psychotherapy (No minimum or maximum hours required) b Couples Families and Children (Minimum 500 hours - up to 150 hours may be

double-counted) c Group Therapy or Counseling (Maximum 500 hours) d Telehealth Counseling (Maximum 375 hours) e Workshops seminars training sessions or conferences directly related to

marriage family and child counseling (Maximum 250 hours) f Personal Psychotherapy Received (Maximum 100 hours triple counted)

2010 amp 2011 2012 amp Later g Administering and evaluating psychological tests of

counselees writing clinical reports and progress or process notes

Max 250 hours Max 500 hours

combined h Client-Centered Advocacy Max 1250 hours

i Direct Supervisor Contact Combined Max

1250 hours Max 1000

hours

LPCC OPTION 1 (new streamlined categories)


bull Direct counseling experience (Minimum 1750 hours) o Must include minimum of 150 hours of clinical experience in a hospital or

community mental health setting

bull Non-clinical experience (Maximum 1250 hours) o May consist of direct supervisor contact administering and evaluating


LPCC OPTION 2 (pre-existing multiple categories)

a Direct Counseling with Individuals Groups Couples or Families (Minimum 1750 hours)

b Group Therapy or Counseling (Maximum 500 hours) c Telehealth Counseling (Maximum 375 hours) d Maximum 1250 hours that include all of the following

bull Workshops seminars training sessions or conferences directly related to professional clinical counseling (Maximum 250 hours)

bull Administering and evaluating psychological tests of counselees writing clinical reports and progress or process notes (Maximum 250 hours)

bull Client-Centered Advocacy

bull Direct Supervisor Contact

NOTE FOR BOTH LPCC OPTIONS

A minimum of 500 hours of supervised experience working directly with couples families or children is required if the applicant wishes to assess or treat couples or families after being issued a LPCC license

37A-525 (Revised 052016)

STATE OF CALIFORNIA ndash 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 wwwbbscagov

MARRIAGE AND FAMILY THERAPIST TRAINEE INTERN

WEEKLY SUMMARY OF HOURS OF EXPERIENCE

OPTION 1 ndash NEW STREAMLINED METHOD

Name of TraineeIntern Last First Middle

Supervisor Name Date enrolled in graduate degree program

Name of Work Setting (use a separate log for each) Address of Work Setting

Indicate your status when the hours below are logged Trainee Post-Degree Intern Application Pending - BBS File No (if known) ________________ Registered Intern - MFT Intern Number _______________

YEAR __________ WEEK OF Total Hours

A Direct Counseling with Individuals Groups Couples or Families

A1 Diagnosis and Treatment of Couples Families Children

B Non-Clinical Experience

B1 Supervision Individual

B2 Supervision Group

C Total Hours Per Week (A + B = C) (Maximum 40 hours week)

Supe

rvis

or

Sign

atur

e

Line A1 is a sub-category of ldquoArdquo and Lines B1 and B2 are subcategories of ldquoBrdquo When totaling weekly

hours do NOT include the subcategories - use the formula found in box ldquoCrdquo

Non-Clinical Experience includes Supervision psychological testing writing clinical reports writing progress or process notes client-centered advocacy and workshops seminars training sessions or conferences

37A-523 (Rev 310) 1

STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY Governor Edmund G Brown Jr



RESPONSIBILITY STATEMENT FOR SUPERVISORS

OF A MARRIAGE AND FAMILY THERAPIST TRAINEE OR INTERN

Title 16 California Code of Regulations (16 CCR) Section 18331 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 TraineeIntern Last First Middle

Name of Qualified Supervisor Qualified Supervisors Daytime Telephone Number

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

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 sect 18331(a)(1) and

Business and Professions Code (BPC) sect 499912 (h))

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 sect 18331(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 sect 18331(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 sect 18331(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 sect 18331(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 sect 18331(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 sect 18331(a)(6)(A)amp(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 sect 18331(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 sect 18331(a)(8))

37A-523 (Rev 310) 2

8) I shall monitor and evaluate the extent kind and quality of counseling performed by the trainee or intern by direct observation review of

audio or video tapes of therapy review of progress and process notes and other treatment records or by any other means deemed appropriate (16 CCR sect 18331(a)(9))

9) I shall address with the trainee or intern the manner in which emergencies will be handled (16 CCR sect 18331(a)(10))

10) I agree not to provide supervision to a TRAINEE unless the trainee is a volunteer or employed in a setting that meets all of the following (A)

lawfully and regularly provides mental health counseling or psychotherapy (B) provides oversight to ensure that the traineersquos work at the setting meets the experience and supervision requirements and is within the scope of practice for the profession as defined in BPC Section 498002 (C) is not a private practice owned by a licensed marriage and family therapist a licensed psychologist a licensed clinical social worker a licensed physician and surgeon or a professional corporation of any of those licensed professions (BPC sect 498043(d)(1))

11) I agree not to provide supervision to an INTERN unless the intern is a volunteer or employed in a setting that meets both of the following (A)

lawfully and regularly provides mental health counseling or psychotherapy (B) provides oversight to ensure that the internrsquos work at the setting meets the experience and supervision requirements and is within the scope of practice for the profession as defined in BPC Section 498002 (BPC sect 498043(e)(1))

12) If I am to provide supervision on a voluntary basis in a setting which is not a private practice a written agreement will be executed between

myself and the organization in which the employer acknowledges that they are aware of the licensing requirements that must be met by the intern or trainee they agree not to interfere with my legal and ethical obligations to ensure compliance with these requirements and they agree to provide me with access to clinical records of the clients counseled by the intern or trainee (16 CCR sect 1833(b)(4))

13) I shall give at least (1) one weeks prior written notice to a trainee or intern of my intent not to sign for any further hours of experience for

such person If I have not provided such notice I shall sign for hours of experience obtained in good faith where I actually provided the required supervision (16 CCR sect 18331(c))

14) I shall obtain from each trainee or intern for whom supervision will be provided the name address and telephone number of the traineersquos

or internrsquos most recent supervisor and employer (16 CCR sect 18331(d))

15) In any setting that is not a private practice I shall evaluate the site(s) where a trainee or intern will be gaining hours of experience toward licensure and shall determine that (1) the site(s) provides experience which is within the scope of practice of a marriage and family therapist and (2) the experience is in compliance with the requirements set forth in 16 CCR Section 1833 and Section 498043 of the Code (16 CCR sect 18331(e))

16) Upon written request of the Board I shall provide to the board any documentation which verifies my compliance with the requirements set

forth in 16 CCR Section 18331 (16 CCR sect 18331(f))

17) I shall provide the intern or trainee with the original of this signed statement prior to the commencement of any counseling or supervision (16 CCR sect 18331(b))

I declare under penalty of perjury under the laws of the State of California that I have read and understand the foregoing and that I meet

all criteria stated herein and that the information submitted on this form is true and correct

_______________________________________ _____________________________________________ _______________ Printed Name of Qualified Supervisor Signature of Qualified Supervisor Date

____________________________________________________________________________________________________________________________________________ Mailing Address Number and Street City State Zip Code

The supervisor shall provide the intern or trainee being supervised with the original of this signed statement prior to the commencement of any counseling or supervision The trainee or intern shall submit this form to the board upon application for examination eligibility Psychologists and Physicians certified in psychiatry are not required to comply with 5 Applies only to supervisors NOT licensed as a Marriage and Family Therapist

Board of Behavioral Sciences LMFT Experience Information for Hours Gained on or after January 1 2012

MIS

CELL

AN

EOU

S D

IREC

T CO

UN

SELI

NG

EXPERIENCE TYPE MINIMUMS AND MAXIMUMS NOTES

1 Individual Counseling or Psychotherapy (performed by you) No Minimum or Maximum No pre- or post-degree hours are required performing individual psychotherapy though many people gain hundreds of hours in this area due to the limitations of other categories

2 Couples Family and Child Psychotherapy (performed by you) Minimum 500 hours May be completed pre- or post-degree or a combination of both Up to 150 hours of conjoint couples and family therapy may be double-counted

3 Group Therapy or Counseling (performed by you) Maximum 500 hours May be completed pre- or post-degree or a combination of both

4 Telehealth Counseling (performed by you) Maximum 375 hours May be completed pre- or post-degree or a combination of both

NOTE - PRE-DEGREE HOURS A maximum of 750 hours of clinical experience (1-4 above) including direct supervisor contact (7 8 next page) can be counted pre-degree EXAMPLE A trainee earns 625 hours of clinical experience comprising a combination of categories 1 2 3 and 4 In addition the trainee earns 125 hours of individual supervision pre-degree for a total of 750 hours

5 Non-Counseling Experience (A-C below) Maximum 1000 hours combined Categories 5A and 5B have their own maximums within the 1000 combined maximum

A Attending Workshops Seminars Training Sessions or Maximum 250 hours May be completed pre- or post-degree or a combination of both Conferences

B Personal Psychotherapy (received by you) Maximum Up to 100 hours may be earned These hours are triple-counted by the Board 100 hours X 3 for a total of 300 Hours may be completed pre- or post-degree or a

combination of both

C Direct Supervisor Contact Maximum 1000 hours Completed both pre- and post-degree For more information see ldquoSupervisionrdquo Minimum 52 weekshours section

6 Administering and Evaluating Psychological Tests Writing Maximum 500 hours May be completed pre- or post-degree or a combination of both Clinical Reports Progress Notes or Process Notes and Client Centered Advocacy

Revised 112


Revised 112


SUPE

RVIS

ION

7 Supervision Individual (One-on-One) Minimum 52 WeeksHours May be completed pre- or post-degree or a combination of both Note These may be non-consecutive weeks

8 Supervision Group No Minimum or Maximum No pre- or post-degree hours are required in this area Not more than eight (8) supervisees are permitted per group Must be provided in one two-hour session or two one-hour segments

NOTE A TOTAL MINIMUM of 104 hoursweeks of supervision is required Persons gaining hours pre- or post-degree must have a minimum of one (1) hour of individual supervision OR two (2) hours of group supervision during each week in which experience is claimed for each work setting (see ratios required below) A maximum of five (5) hours of supervision may be credited per week

SUPERVISION RATIOS REQUIRED FOR DIRECT COUNSELING EXPERIENCE Ratio - Hours of Clinical Experience to Units of Supervision (One unit of supervision is equal to one (1) hour of individual or two (2) hours of group supervision)

Trainees Minimum one (1) unit of supervision for every five (5) hours of

client contact in each setting

Post-degree Minimum one (1) unit of supervision each week in each setting

AND one additional unit during any week in which more than ten (10) hours of client

contact is gained in each setting

For trainees ratios can be calculated based on the average number of hours gained over the entire period of time a trainee works in a particular setting

Supervision ratios cannot be averaged for persons gaining hours post-degree

For examples of how to apply supervision ratios see ldquoAnswers to Most Frequently Asked Questions Relating to MFT Interns and Traineesrdquo

TOTA

LS

WEEKS OF EXPERIENCE REQUIRED Minimum 104 weeks Completed pre and post degree

TOTAL HOURS OF EXPERIENCE REQUIRED

PRE-DEGREE Maximum 1300 hrs

POST-DEGREE Minimum 1700 hrs

1300 maximum pre-degree hours = 750 maximum counseling and supervision (categories 1-4 7 8) + all remaining hours categories

TOTAL Minimum 3000 hours

The information provided in this publication is general and intended to serve as a quick answer guide for common questions The Statutes and Regulations Relating to the Practice of Professional Clinical Counseling Marriage and Family Therapy Educational Psychology and Clinical Social Work contains the official legal code sections and language The Board of Behavioral Sciences encourages you to thoroughly read the Statutes and Regulations and refer to it in cases that require official legal language

37M-803 (Rev 111)




MARRIAGE AND FAMILY THERAPIST TRAINEE AND INTERN SUPERVISION INFORMATION

General Qualifications Licensed mental health professionals interested in providing supervision to Marriage and Family Therapists (MFT) Trainees and Interns must meet certain minimum qualifications in order to supervise The qualifications differ depending on the license type of the potential supervisor Listed below are the licensed mental health professionals authorized to supervise MFT Trainees and Interns and some of the general qualifications needed to provide supervision to a MFT Trainee or Intern For further specific information please review sections 1833 ndash 18332 of Title 16 of the California Code of Regulations This information only applies to those supervising MFT Trainees and Interns Marriage and Family Therapist ndash MFTs must possess

bull a current and valid California license for at least two years prior to the commencement of supervision bull complete a 6-hour supervision training within 60 days of commencement of supervision and every renewal period

thereafter bull and practiced psychotherapy or provided direct supervision of ASWs Marriage and Family Therapist (MFT) Trainees

or Interns who performed psychotherapy in two of the past five years immediately preceding the commencement of supervision

Licensed Clinical Social Worker (LCSW) ndash LCSWs must possess

bull a current and valid California license for at least two years prior to the commencement of supervision bull complete a 6 hour supervision training within 60 days of commencement of supervision and every renewal period



Six Hour Supervision Training LCSWs and MFTs supervising MFT Trainees and Interns must complete a minimum of six hours of supervision training or coursework (usually one course) prior to commencement of supervision and every renewal period thereafter MFT Trainee and Intern Supervised Experience Requirements The Board has several resources relating to the supervision and experience requirements including

BBS Home page ndash wwwbbscagov Forms and Publications (download forms FAQs etc) - wwwbbscagovformsshtml MFT Licensure Walk-Through (refresh your memory on the required steps to obtain licensure) -

wwwbbscagovapp-regmft_part1shtml Experience Calculators (use a pre-formatted spreadsheet to calculate information relating to experience

requirements) - wwwbbscagovapp-regexp_calcshtml Online LicenseRegistration Verification (verify licenses and registrations instantly) - wwwbbscagovapp-

regmft_part1shtml BBS Subscriber List (stay up to date on the latest BBS related news and laws) -

wwwbbscagovquick_linkssubscribeshtml Board Meetings Calendar (check for meetings in your area attend and be heard) -

wwwbbscagovbd_activitybd_mtgsshtml Outreach Events (keep up on upcoming outreach events) - wwwbbscagovbd_activityoutreachshtml

The Value of Supervision

The value of clinical supervision to your development as a mental health professional cannot be emphasized enough Itrsquos important that you make the most out of the opportunity to benefit from the knowledge and experience of a licensed mental health professional and to develop a strong relationship that will facilitate your growth as a psychotherapist In order to make the most of the supervision experience it is critical that both you and your supervisor are aware of each partyrsquos responsibilities in the supervision process including the legal and ethical requirements pertaining to supervision California law requires at least two (2) years of supervised experience to qualify for licensure however the value of the relationship with your supervisor goes further than merely qualifying you for licensure

Developing a Strong Relationship

The amount of time you are able to spend with your supervisor is often limited Below are several strategies that may help you maximize the time that you do have with your supervisor

bull Spend some time at the beginning of your supervisory relationship setting goals and objectives

bull Set aside time in future meetings to revisit these goals and objectives

bull Be proactive with your supervisor Make sure you are getting the value that you expected from supervision Supervision should be a collaborative experience

bull Thoroughly read the Responsibility Statement for Supervisors of a Marriage and Family Therapist Trainee or Intern This form outlines the supervisorrsquos legal requirements pertaining to the licensure process and must be signed by the supervisor upon commencement of supervision

Donrsquot Be Afraid to Ask Questions

Below are some questions you may want to ask your supervisor in order to provide you with a better understanding of your supervisorrsquos qualifications professional background and knowledge base

Questions to consider asking include

bull What type of license do you possess

bull Is your license current and valid

bull When were you licensed

bull Have you completed the mandatory supervision course

bull Have you met the requirement of having practiced psychotherapy or supervised Marriage and Family Therapist (MFT) Interns MFT Trainees Professional Clinical Counselor Interns or Trainees or Associate Clinical Social Workers who perform psychotherapy for at

least two (2) years within the last five (5) years

bull Have you ever provided supervision to a MFT Intern or Trainee before and if so how many

bull What is your practice background (private practice agency school etc)

bull Do you practice from a particular theoretical orientation and if so will other theoretical orientations be discussed

bull Do you have any specialty areas of practice

Preparing for the Licensing Examinations

Effective clinical supervision should help prepare you to pass the licensing exams You can help ensure that you get what you need out of supervision by taking the following steps bull Download the examination candidate

handbooks from the BBS website

bull Review the sample questions and exam content outlines then take them to your supervisor and discuss how your work is preparing you for the exams Revisit periodically to ensure your supervision and experience supports your goal of licensure

bull Ask your supervisor for suggestions on effective exam preparation strategies

bull Carefully read the exam information provided on the Boardrsquos website by

selecting the Applicants tab and then clicking the Exams link

Know Your Supervised Experience Requirements

Supervisors often supervise multiple individuals working towards different professional licenses all with different experience and supervision requirements Therefore it is critical that you become knowledgeable about your professionrsquos specific requirements Here are some resources available to help you understand the supervised experience requirements for the marriage and family therapist profession

bull The Applicants section of the BBS website

bull Frequently Asked Questions Relating to MFT Trainees and Interns available on the Boardrsquos website

bull Current and past issues of the BBS Newsletter available on the Boardrsquos website

bull Professional MFT associations

Your Supervisorrsquos License Status Your supervisorrsquos license status must be current and active while you are under supervision in order for your hours to count Visit the ldquoBreezerdquo License Search to verify your supervisorrsquos license status Do this upon commencement of supervision and make note of the expiration date

Check again near your supervisorrsquos expiration date to ensure his or her license has been renewed so that you do not lose any hours

Your Registrationrsquos Status Once you are an MFT Intern registered with the BBS the status of your registration is important too Renew your registration early to ensure no hours are lost due to a delinquent renewal

Complaints Against a Supervisor Supervisees who wish to file a complaint against their supervisor can do so using the Consumer Complaint Form or through the ldquoBreezerdquo online system

Who to Contact for Questions

For questions regarding experience and supervision requirements you can email the MFT evaluators directly at BBSLMFTdcacagov The Boardrsquos entire email directory is on the Boardrsquos website under Contact Us

Stay Informed

To receive updates regarding law changes enforcement actions meetings and more sign up for the Boardrsquos email subscriberrsquos list

A Guide to Supervision for Marriage and Family Therapist Interns and Trainees

______________________ Board of Behavioral Sciences

1625 N Market Blvd Suite S-200 Sacramento CA 95834

(916) 574-7830 wwwbbscagov

(Revised 052016)

CHANGES TO THE LAW FOR MARRIAGE AND FAMILY THERAPIST INTERNS AND TRAINEES

DISCLOSURES AND ADVERTISING AB 956 (Chapter 166 Statutes of 2011) makes several changes in law regarding disclosures to patients as well as advertisements for marriage and family therapy services These changes will become effective on January 1 2012 The changes to the law are as follows

MFT Interns

1 Disclosure Requires an unlicensed marriage and family therapist intern to provide each

client or patient prior to performing any professional services with the following information (BPC sect498044(c))

a That he or she is an unlicensed marriage and family therapist registered intern (current law)

b His or her registration number (new provision)

c The name of his or her employer (new provision) and

d Indicate whether he or she is under the supervision of a licensed marriage and family therapist licensed clinical social worker licensed psychologist or a licensed physician and surgeon certified in psychiatry by the American Board of Psychiatry and Neurology (current law but now the MFT intern must indicate the type of supervising licensee)

2 Advertising Requires any advertisement by or on behalf of a marriage and family therapist intern must include at a minimum all of the following (BPC sect498044(d))

a That he or she is a marriage and family therapist registered intern

b The internrsquos registration number

c The name of his or her employer and

d That he or she is supervised by a licensed person

The use of the abbreviation ldquoMFTIrdquo in an advertisement is prohibited unless the title ldquomarriage and family therapist registered internrdquo appears in the advertisement (BPC sect498044(d)(2))

MFT Trainees

1 Disclosure Requires an MFT trainee to inform each client or patient prior to performing any professional services of the following (BPC sect498048(a))

a That he or she is an unlicensed marriage and family therapist trainee (current law)

b The name of his or her employer (new provision)

c Indicate whether he or she is under the supervision of a licensed marriage and family therapist licensed clinical social worker licensed psychologist or a licensed physician certified in psychiatry by the American Board of Psychiatry and Neurology (current law but now the MFT trainee must indicate the type of supervising licensee)

2 Advertising Requires any advertisement of services performed by a trainee must include at a minimum all of the following (BPC sect498048(b) and (c))

a Traineersquos name and that he or she is a marriage and family therapist trainee

b The name of his or her employer and

c That he or she is supervised by a licensed person and the supervisorrsquos license designation or abbreviation and license number

13 LPCC13 Specific13 Documents13

13

bull Note13 that13 there13 are13 more13 hours13 (28013 pre-shy‐degree13 direct13 face-shy‐to-shy‐face13 clinical13 contact)13 required13 for13 the13 LPCC13 13 13 13

bull Note13 that13 no13 pre-shy‐degree13 hours13 count13 toward13 the13 300013 required13 for13 licensure13

13

bull Note13 you13 will13 need13 to13 take13 a13 Career13 Counseling13 course13 o At13 SJSU13 this13 is13 13 EDCO13 26613 Education13 and13 Career13 Planning13 (313 units)13

13

13

Licensed Professional Clinical Counselor (LPCC) In-State Applicant Requirements

The following is a brief overview of the requirements for an in-state LPCC applicant In-state applicants must register as a Professional Clinical Counselor Intern (PCCI)upon graduation in order to gain hours of experience Upon receipt of an application deficiency notice if one is necessary the applicant will have one year to remedy anyapplication deficiencies identified in the BBS evaluation The intern registration cannot be issued until deficiencies have been resolved

EDUCATION REQUIREMENTS

The education requirements described in the sections below apply only to applicants who enroll in a qualifying degree program on or after August 1 2012 or whocomplete their current degree program after December 31 2018 (Sources Business and Professions Code Section 499933 California Code of Regulations Title 16 Section 1806)

Please see the Boardrsquos Pre-2012 LPCC In-State Applicant Requirements for qualifying degree programs beginning prior to August 1 2012 and completed prior toDecember 31 2018

Degree Requirements

Applicants must possess a masters or doctoral degree that is at least 60 semester or 90 quarter units and counseling or psychotherapy in content and from a regionallyaccredited or Bureau for Private Postsecondary Education (BPPE) approved institution as defined under BPC Section 499912 Specifically this means a degree mustinclude

10 of 13 Core Content AreasSix semester or nine quarter units of supervised practicum or field study with a minimum of 280 hours of face-to-face supervised clinicalexperience counseling individuals families or groups andA minimum of 15 semester units or 225 quarter units of advanced coursework

If an applicants degree includes only 10 of the 13 core content areas the missing three content areas must be remediated via post-masters or postdoctoral coursework ata regionally accredited or BPPE approved institution as defined under BPC Section 499912 LPCC programs offering the required coursework may be found through theCalifornia Association of Licensed Professional Clinical Counselors (CALPCC) website or the Boards Schools with LPCC-related Programs page

SUPERVISED WORK EXPERIENCE REQUIREMENTS

Supervised work experience must be gained after the conferral date of the applicantrsquos qualifying degree All hours of supervised work experience must be gained whileregistered as a PCCI with the exception of the following

Supervised work experience hours gained immediately after graduation but prior to registration as a PCCI may be credited towards experiencerequirements provided they

Apply for PCCI registration within 90 days of the qualifying degree conferral date andComplete application deficiencies within one year of being notified and receive the registration number

Supervised work experience gained out of state no more than six years prior to the date the application for examination eligibility is filed

Additionally a PCCI cannot work or gain supervised experience in a private practice setting until officially registered with the BBS

Supervised WeeksIn order to qualify for licensure examination eligibility a PCCI must complete at least 104 weeks of supervision The minimum amount of supervision required per week iseither one hour of individual supervision or two hours of group supervision Of the 104 weeks of supervision at least 52 weeks must be weeks in which the registrantreceived at least one hour of individual supervision

A PCCI working in a governmental entity a school a college or a university or an institution that is both non-profit and charitable may obtain the required directsupervisor contact via videoconferencing

Hours of Experience

In order to claim any work experience towards the required 3000 hours of experience a PCCI must receive at least one hour of individual supervision or two hours ofgroup supervision during the same week that the hours were gained A PCCI who earns in excess of 10 hours of direct counseling work experience in a week must obtainone additional hour of individual or two additional hours of group supervision A maximum of 40 hours of work experience may be gained in a week

Additionally at least 150 hours of clinical experience must be gained in a hospital or community mental health setting Detailed breakdowns for the categories ofsupervised experience which an applicant may claim are found in the Boardrsquos New Option for Supervised Experience Categories document

EXAMINATION ELIGIBILITY

Once a PCCI meets all experience requirements they will submit the application for examination eligibility The law stipulates that at the time the Board receives theapplication for examination eligibility the qualifying supervised work experience shall be gained no more than six years prior to application

For example the BBS receives Susans application for LPCC examination eligibility on April 27 2013 The hours of supervised work experience earned between April 272007 and April 27 2013 will meet the six-year requirement

EXAMINATIONS

Applicants must receive a passing score on the following examinations






1 California Law and Ethics Examination2 National Clinical Mental Health Counselor Examination (NCMHCE)

Applicants must first pass the California Law and Ethics Examination before they can take the NCMHCE Please continue to check the Boars web-site for future updatesrelating to LPCC licensure requirements

(Sources Business and Professions Code Sections 499945 499946 California Code of Regulations Title 16 Section 1820)

FINGERPRINTING REQUIREMENTS

All applicants must be fingerprinted with the BBS The Applicant Fingerprinting Requirements provides specific information on the fingerprinting process

APPLICATION PACKETS

Professional Clinical Counselor Intern Registration In-State ApplicationLicensed Professional Clinical Counselor In-State Application for Licensure and Examination ndash For applicants with in-state degrees and hold aPCCI registration

Requirements13 for13 LPC13 Licensure13 13 Taken13 from13 the13 BBS13 LPC13 appkication13 packet13 section13 titled13 ldquoPROFESSIONAL13 CLINICAL13 COUNSELOR13 IN-shy‐STATE13 DEGREE13 PROGRAM13 CERTIFICATION13 FORM13 Brdquo13 (37A-shy‐66713 (Revised13 012017)13 13 13 Item13 413 13 The13 degree13 program13 contained13 13

13 1 TOTAL13 UNITS13 At13 least13 6013 semester13 or13 9013 quarter13 units13 of13 instruction13

13 2 CORE13 CONTENT13 AREAS13 Fulfills13 the13 core13 content13 areas13 as13 reported13 to13

and13 accepted13 by13 the13 Board13 for13 this13 program13 13

3 ADVANCED13 COURSEWORK13 (in13 ADDITION13 to13 rdquoCore13 Contentrdquo13 courses)13 1513 semester13 or13 22513 quarter13 units13

13 4 PRACTICUM13 OR13 FIELD13 STUDY13 At13 least13 613 semester13 or13 913 quarter13 units13

that13 included13 a13 minimum13 of13 28013 supervised13 hours13 providing13 face-shy‐to-shy‐face13 clinical13 counseling13 of13 individuals13 families13 or13 groups13

13 5 ADDITIONAL13 CONTENT13 As13 required13 by13 BPC13 section13 49993313

13 Here13 is13 a13 copy13 of13 the13 BPC13 section13 noted13 above13 13 (a)13 This13 section13 shall13 apply13 to13 the13 following13

(1)13 Applicants13 for13 examination13 eligibility13 or13 registration13 who13 begin13 graduate13 study13 before13 August13 113 201213 and13 do13 not13 complete13 that13 study13 on13 or13 before13 December13 3113 201813 (2)13 Applicants13 for13 examination13 eligibility13 or13 registration13 who13 begin13 graduate13 study13 before13 August13 113 201213 and13 who13 graduate13 from13 a13 degree13 program13 that13 meets13 the13 requirements13 of13 this13 section13 (3)13 Applicants13 for13 examination13 eligibility13 or13 registration13 who13 begin13 graduate13 study13 on13 or13 after13 August13 113 201213 13

(b)13 To13 qualify13 for13 examination13 eligibility13 or13 registration13 applicants13 shall13 possess13 a13 masters13 or13 doctoral13 degree13 that13 is13 counseling13 or13 psychotherapy13 in13 content13 and13 that13 meets13 the13 requirements13 of13 this13 section13 obtained13 from13 an13 accredited13 or13 approved13 institution13 as13 defined13 in13 Section13 49991213 13 For13 purposes13 of13 this13 subdivision13 a13 degree13 is13 ldquocounseling13 or13 psychotherapy13 in13 contentrdquo13 if13 it13 contains13 the13 supervised13 practicum13 or13 field13 study13 experience13 described13 in13 paragraph13 (3)13 of13 subdivision13 (c)13 and13 except13 as13 provided13 in13 subdivision13 (f)13 the13 coursework13 in13 the13 core13 content13 areas13 listed13 in13 subparagraphs13 (A)13 to13 (M)13 inclusive13 of13 paragraph13 (1)13 of13 subdivision13 (c)13 13 (c)13 The13 degree13 described13 in13 subdivision13 (b)13 shall13 contain13 not13 less13 than13 6013 graduate13 semester13 or13 9013 graduate13 quarter13 units13 of13 instruction13 which13 shall13 except13 as13 provided13 in13 subdivision13 (f)13 include13 all13 of13 the13 following13

(1)13 The13 equivalent13 of13 at13 least13 three13 semester13 units13 or13 four13 and13 one-shy‐half13 quarter13 units13 of13 graduate13 study13 in13 all13 of13 the13 following13 core13 content13 areas13

(A)13 Counseling13 and13 psychotherapeutic13 theories13 and13 techniques13 including13 the13 counseling13 process13 in13 a13 multicultural13 society13 an13 orientation13 to13 wellness13 and13

prevention13 counseling13 theories13 to13 assist13 in13 selection13 of13 appropriate13 counseling13 interventions13 models13 of13 counseling13 consistent13 with13 current13 professional13 research13 and13 practice13 development13 of13 a13 personal13 model13 of13 counseling13 and13 multidisciplinary13 responses13 to13 crises13 emergencies13 and13 disasters13 (B)13 Human13 growth13 and13 development13 across13 the13 lifespan13 including13 normal13 and13 abnormal13 behavior13 and13 an13 understanding13 of13 developmental13 crises13 disability13 psychopathology13 and13 situational13 and13 environmental13 factors13 that13 affect13 both13 normal13 and13 abnormal13 behavior13 (C)13 Career13 development13 theories13 and13 techniques13 including13 career13 development13 decisionmaking13 models13 and13 interrelationships13 among13 and13 between13 work13 family13 and13 other13 life13 roles13 and13 factors13 including13 the13 role13 of13 multicultural13 issues13 in13 career13 development13 (D)13 Group13 counseling13 theories13 and13 techniques13 including13 principles13 of13 group13 dynamics13 group13 process13 components13 group13 developmental13 stage13 theories13 therapeutic13 factors13 of13 group13 work13 group13 leadership13 styles13 and13 approaches13 pertinent13 research13 and13 literature13 group13 counseling13 methods13 and13 evaluation13 of13 effectiveness13 (E)13 Assessment13 appraisal13 and13 testing13 of13 individuals13 including13 basic13 concepts13 of13 standardized13 and13 nonstandardized13 testing13 and13 other13 assessment13 techniques13 norm-shy‐referenced13 and13 criterion-shy‐referenced13 assessment13 statistical13 concepts13 social13 and13 cultural13 factors13 related13 to13 assessment13 and13 evaluation13 of13 individuals13 and13 groups13 and13 ethical13 strategies13 for13 selecting13 administering13 and13 interpreting13 assessment13 instruments13 and13 techniques13 in13 counseling13 (F)13 Multicultural13 counseling13 theories13 and13 techniques13 including13 counselors13 roles13 in13 developing13 cultural13 self-shy‐awareness13 identity13 development13 promoting13 cultural13 social13 justice13 individual13 and13 community13 strategies13 for13 working13 with13 and13 advocating13 for13 diverse13 populations13 and13 counselors13 roles13 in13 eliminating13 biases13 and13 prejudices13 and13 processes13 of13 intentional13 and13 unintentional13 oppression13 and13 discrimination13 (G)13 Principles13 of13 the13 diagnostic13 process13 including13 differential13 diagnosis13 and13 the13 use13 of13 current13 diagnostic13 tools13 such13 as13 the13 current13 edition13 of13 the13 Diagnostic13 and13 Statistical13 Manual13 the13 impact13 of13 co-shy‐occurring13 substance13 use13 disorders13 or13 medical13 psychological13 disorders13 established13 diagnostic13 criteria13 for13 mental13 or13 emotional13 disorders13 and13 the13 treatment13 modalities13 and13 placement13 criteria13 within13 the13 continuum13 of13 care13 (H)13 Research13 and13 evaluation13 including13 studies13 that13 provide13 an13 understanding13 of13 research13 methods13 statistical13 analysis13 the13 use13 of13 research13 to13 inform13 evidence-shy‐based13 practice13 the13 importance13 of13 research13 in13 advancing13 the13 profession13 of13 counseling13 and13 statistical13 methods13 used13 in13 conducting13 research13 needs13 assessment13 and13 program13 evaluation13 (I)13 Professional13 orientation13 ethics13 and13 law13 in13 counseling13 including13 California13 law13 and13 professional13 ethics13 for13 professional13 clinical13 counselors13 professional13 ethical13 standards13 and13 legal13 considerations13 licensing13 law13 and13 process13 regulatory13 laws13 that13 delineate13 the13 professions13 scope13 of13 practice13 counselor-shy‐client13 privilege13 confidentiality13 the13 client13 dangerous13 to13 self13 or13 others13 treatment13 of13 minors13 with13 or13 without13 parental13 consent13 relationship13 between13 practitioners13 sense13 of13 self13 and13 human13 values13 functions13 and13 relationships13 with13 other13 human13 service13 providers13 strategies13 for13 collaboration13 and13 advocacy13 processes13 needed13 to13 address13 institutional13 and13 social13 barriers13 that13 impede13 access13 equity13 and13 success13 for13 clients13 (J)13 Psychopharmacology13 including13 the13 biological13 bases13 of13 behavior13 basic13 classifications13 indications13 and13 contraindications13 of13 commonly13 prescribed13 psychopharmacological13 medications13 so13 that13 appropriate13 referrals13 can13 be13 made13 for13 medication13 evaluations13 and13 so13 that13 the13 side13 effects13 of13 those13 medications13 can13 be13 identified13 (K)13 Addictions13 counseling13 including13 substance13 abuse13 co-shy‐occurring13 disorders13 and13 addiction13 major13 approaches13 to13 identification13 evaluation13 treatment13 and13 prevention13

of13 substance13 abuse13 and13 addiction13 legal13 and13 medical13 aspects13 of13 substance13 abuse13 populations13 at13 risk13 the13 role13 of13 support13 persons13 support13 systems13 and13 community13 resources13 (L)13 Crisis13 or13 trauma13 counseling13 including13 crisis13 theory13 multidisciplinary13 responses13 to13 crises13 emergencies13 or13 disasters13 cognitive13 affective13 behavioral13 and13 neurological13 effects13 associated13 with13 trauma13 brief13 intermediate13 and13 long-shy‐term13 approaches13 and13 assessment13 strategies13 for13 clients13 in13 crisis13 and13 principles13 of13 intervention13 for13 individuals13 with13 mental13 or13 emotional13 disorders13 during13 times13 of13 crisis13 emergency13 or13 disaster13 (M)13 Advanced13 counseling13 and13 psychotherapeutic13 theories13 and13 techniques13 including13 the13 application13 of13 counseling13 constructs13 assessment13 and13 treatment13 planning13 clinical13 interventions13 therapeutic13 relationships13 psychopathology13 or13 other13 clinical13 topics13

(2)13 In13 addition13 to13 the13 course13 requirements13 described13 in13 paragraph13 (1)13 1513 semester13 units13 or13 22513 quarter13 units13 of13 advanced13 coursework13 to13 develop13 knowledge13 of13 specific13 treatment13 issues13 or13 special13 populations13 (3)13 Not13 less13 than13 six13 semester13 units13 or13 nine13 quarter13 units13 of13 supervised13 practicum13 or13 field13 study13 experience13 or13 the13 equivalent13 in13 a13 clinical13 setting13 that13 provides13 a13 range13 of13 professional13 clinical13 counseling13 experience13 including13 the13 following13

(A)13 Applied13 psychotherapeutic13 techniques13 (B)13 Assessment13 (C)13 Diagnosis13 (D)13 Prognosis13 (E)13 Treatment13 (F)13 Issues13 of13 development13 adjustment13 and13 maladjustment13 (G)13 Health13 and13 wellness13 promotion13 (H)13 Professional13 writing13 including13 documentation13 of13 services13 treatment13 plans13 and13 progress13 notes13 (I)13 How13 to13 find13 and13 use13 resources13 (J)13 Other13 recognized13 counseling13 interventions13 (K)13 A13 minimum13 of13 28013 hours13 of13 face-shy‐to-shy‐face13 supervised13 clinical13 experience13 counseling13 individuals13 families13 or13 groups13 13

(d)13 The13 6013 graduate13 semester13 units13 or13 9013 graduate13 quarter13 units13 of13 instruction13 required13 pursuant13 to13 subdivision13 (c)13 shall13 in13 addition13 to13 meeting13 the13 requirements13 of13 subdivision13 (c)13 include13 instruction13 in13 all13 of13 the13 following13

(1)13 The13 understanding13 of13 human13 behavior13 within13 the13 social13 context13 of13 socioeconomic13 status13 and13 other13 contextual13 issues13 affecting13 social13 position13 (2)13 The13 understanding13 of13 human13 behavior13 within13 the13 social13 context13 of13 a13 representative13 variety13 of13 the13 cultures13 found13 within13 California13 (3)13 Cultural13 competency13 and13 sensitivity13 including13 a13 familiarity13 with13 the13 racial13 cultural13 linguistic13 and13 ethnic13 backgrounds13 of13 persons13 living13 in13 California13 (4)13 An13 understanding13 of13 the13 effects13 of13 socioeconomic13 status13 on13 treatment13 and13 available13 resources13 (5)13 Multicultural13 development13 and13 cross-shy‐cultural13 interaction13 including13 experiences13 of13 race13 ethnicity13 class13 spirituality13 sexual13 orientation13 gender13 and13 disability13 and13 their13 incorporation13 into13 the13 psychotherapeutic13 process13 (6)13 Case13 management13 systems13 of13 care13 for13 the13 severely13 mentally13 ill13 public13 and13 private13 services13 for13 the13 severely13 mentally13 ill13 community13 resources13 for13 victims13 of13 abuse13 disaster13 and13 trauma13 response13 advocacy13 for13 the13 severely13 mentally13 ill13 and13 collaborative13 treatment13 13 The13 instruction13 required13 in13 this13 paragraph13 may13 be13 provided13 either13 in13 credit13 level13 coursework13 or13 through13 extension13 programs13 offered13 by13 the13 degree-shy‐granting13 institution13 (7)13 Human13 sexuality13 including13 the13 study13 of13 the13 physiological13 psychological13 and13 social13 cultural13 variables13 associated13 with13 sexual13 behavior13 gender13 identity13 and13 the13 assessment13 and13 treatment13 of13 psychosexual13 dysfunction13

(8)13 Spousal13 or13 partner13 abuse13 assessment13 detection13 intervention13 strategies13 and13 same-shy‐gender13 abuse13 dynamics13 (9)13 Child13 abuse13 assessment13 and13 reporting13 (10)13 Aging13 and13 long-shy‐term13 care13 including13 biological13 social13 cognitive13 and13 psychological13 aspects13 of13 aging13 13 This13 coursework13 shall13 include13 instruction13 on13 the13 assessment13 and13 reporting13 of13 as13 well13 as13 treatment13 related13 to13 elder13 and13 dependent13 adult13 abuse13 and13 neglect13 13

(e)13 A13 degree13 program13 that13 qualifies13 for13 licensure13 under13 this13 section13 shall13 do13 all13 of13 the13 following13 (1)13 Integrate13 the13 principles13 of13 mental13 health13 recovery-shy‐oriented13 care13 and13 methods13 of13 service13 delivery13 in13 recovery-shy‐oriented13 practice13 environments13 (2)13 Integrate13 an13 understanding13 of13 various13 cultures13 and13 the13 social13 and13 psychological13 implications13 of13 socioeconomic13 position13 (3)13 Provide13 the13 opportunity13 for13 students13 to13 meet13 with13 various13 consumers13 and13 family13 members13 of13 consumers13 of13 mental13 health13 services13 to13 enhance13 understanding13 of13 their13 experience13 of13 mental13 illness13 treatment13 and13 recovery13 13

(f)(1)13 An13 applicant13 whose13 degree13 is13 deficient13 in13 no13 more13 than13 three13 of13 the13 required13 areas13 of13 study13 listed13 in13 subparagraphs13 (A)13 to13 (M)13 inclusive13 of13 paragraph13 (1)13 of13 subdivision13 (c)13 may13 satisfy13 those13 deficiencies13 by13 successfully13 completing13 post-shy‐masters13 or13 postdoctoral13 degree13 coursework13 at13 an13 accredited13 or13 approved13 institution13 as13 defined13 in13 Section13 49991213

(2)13 Coursework13 taken13 to13 meet13 deficiencies13 in13 the13 required13 areas13 of13 study13 listed13 in13 subparagraphs13 (A)13 to13 (M)13 inclusive13 of13 paragraph13 (1)13 of13 subdivision13 (c)13 shall13 be13 the13 equivalent13 of13 three13 semester13 units13 or13 four13 and13 one-shy‐half13 quarter13 units13 of13 study13 (3)13 The13 board13 shall13 make13 the13 final13 determination13 as13 to13 whether13 a13 degree13 meets13 all13 requirements13 including13 but13 not13 limited13 to13 course13 requirements13 regardless13 of13 accreditation13 13 -shy‐13 See13 more13 at13 httpcodesfindlawcomcabusiness-shy‐and-shy‐professions-shy‐codebpc-shy‐sect-shy‐4999-shy‐33htmlsthashU8NABfuTdpuf13 13

13




LICENSED PROFESSIONAL CLINICAL COUNSELORS

ASSESSMENT AND TREATMENT OF COUPLES AND FAMILIES

The scope of practice for Licensed Professional Clinical Counselors (LPCCs) includes the assessment and treatment of individuals and groups It does not include the assessment or treatment of couples or families unless the LPCC meets specific qualifications defined in California law as follows

Scope of Practice Qualifications to Assess and Treat Couples and Families

1 Six (6) semester units or nine (9) quarter units specifically focused on the theory and application of marriage and family therapy OR a named specialization or emphasis area on the qualifying degree in marriage and family therapy marital and family therapy marriage family and child counseling or couple and family therapy

AND 2 No less than 500 hours of documented supervised experience working directly with

couples families or children AND

3 A minimum of six (6) hours of continuing education (CE) specific to marriage and family therapy during each license renewal cycle The six (6) hours will count toward the required overall 36 hours of CE

NEW REQUIREMENT EFFECTIVE JANUARY 1 2017 Board Confirmation of Qualifications Must be Provided to Clients and Supervisees

Effective January 1 2017 LPCCs must obtain written confirmation from the Board stating that he or she meets the requirements to assess and treat couples and families prior to assessing or treating a couple or family client Additionally LPCCs must do the following

x Provide a copy of the Boardrsquos written confirmation to couple or family clients prior to commencement of treatment LPCCs already in the process of treating a couple or family must provide the client with a copy of the confirmation before any further sessions take place on or after January 1 2017 AND

Business and Professions Code section 499920 and Title 16 California Code of Regulations sections 18205 and 18207 available in the Boardrsquos Statutes and Regulations

Revised 072016 1 of 2

x Provide a copy of the Boardrsquos written confirmation to the types of supervisees listed below prior to commencement of supervision

o A marriage and family therapist trainee or intern

o An LPCC or PCC Intern who is gaining the supervised experience necessary to treat couples or families

o LPCCs already in the process of supervising any of the above individuals must provide the supervisee with a copy of the confirmation before any further supervision is conducted on or after January 1 2017

The Request for Confirmation of Qualifications to Assess and Treat Couples and Families form is available on the Boardrsquos website

Obtaining Supervised Experience with Couples Families or Children

Professional Clinical Counselor Interns and LPCC licensees are temporarily exempt from the scope of practice limitation while gaining supervised experience if obtained under the direct supervision of any of the following California licensees who have been practicing for at least two (2) years

x An LPCC who has already met the scope of practice qualifications to treat couples and families and after January 1 2017 has obtained written confirmation from the Board of meeting the qualifications to treat couples and families

x A Licensed Marriage and Family Therapist OR

x Any of the following who have sufficient education and experience in treating couples and families to competently practice couples and family therapy in California

o Licensed Clinical Social Worker

o Licensed Clinical Psychologist

o Licensed Physician Certified in Psychiatry by the American Board of Psychiatry and Neurology

Additionally the supervisor must have received professional training in supervision may not have provided therapeutic services to the supervisee and must have a current and valid license that is not under suspension or probation

Professional Clinical Counselor StudentsTrainees are permitted to treat couples and families as part of their supervised practicum experience but may not count that experience toward the 500 hours required to treat couples and families

2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)




PROFESSIONAL CLINICAL COUNSELOR INTERN

WEEKLY SUMMARY OF EXPERIENCE HOURS

OPTION 1 ndash NEW STREAMLINED METHOD Use a separate log for each work setting

Name of Intern Last First Middle

Supervisor Name Name of Work Setting

Address of Work Setting Is this a hospital or community mental health setting

Yes No

Indicate your status when the hours below are logged BBS File ________________

Intern Application Pending Registered Intern - PCI Number _______________

YEAR ________ WEEK OF Total Hours






Of the above hours how many included working with Couples Families or Children

Supe

rvis

or

Sign

atur

e

Lines B1 and B2 are sub-categories of line ldquoBrdquo When totaling weekly hours do not include the subcategories - use the formula found in box ldquoCrdquo






OF A PROFESSIONAL CLINICAL COUNSELOR INTERN

Title 16 California Code of Regulations (16 CCR) Section 1821 requires any qualified licensed mental health professional who assumes responsibility for providing supervision to those working toward a Professional Clinical Counselor (PCC) license to complete and sign under penalty of perjury the following statement prior to the commencement of any counseling or supervision

Name of PCC Intern Last First Middle


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 sect 1821)(b)(1) and Business and Professions Code (BPC) sect 499912(h)(1))


Licensed Professional Clinical Counselor License Issue Date

Marriage and Family Therapist License Issue Date Licensed Clinical Social Worker License Issue Date Licensed Clinical Psychologist License Issue Date Licensed Physician and Surgeon who is certified in psychiatry by the American Board of Psychiatry and Neurology

License Issue Date

B I have had sufficient experience training and education in professional clinical counseling to competently practice professional

clinical counseling in California (16 CCRsect 1821(b)(2))

C I will keep myself informed about developments in professional clinical counseling and in California law governing the practice of professional clinical counseling (16 CCR sect 1821(b)(3))

2) I have and maintain a current and valid license in good standing and will immediately notify any 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 sect 1821(b)(4))

3) I have practiced psychotherapy or provided direct supervision of trainees interns or associate clinical social workers who perform

psychotherapy for at least two (2) years within the five (5) year period immediately preceding this supervision (16 CCR sect 1821(b)(5))

4) I have had sufficient experience training and education in the area of clinical supervision to competently supervise interns (16 CCR sect 1821(b)(6))

5) I have completed six (6) hours of supervision training or coursework within the two-year 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 sect 1821(b)(6)(A) and (B))

6) I know and understand the laws and regulations pertaining to both the supervision of interns and the experience required for licensure as a

licensed professional clinical counselor (16 CCR sect 1821(b)(7))

37A-643 (new 310) 1

7) I shall ensure that the extent kind and quality of counseling performed is consistent with the education training and experience of the intern (16 CCR sect 1821(b)(8))

8) I shall monitor and evaluate the extent kind and quality of counseling performed by the intern by direct observation review of audio or video

tapes of therapy review of progress and process notes and other treatment records or by any other means deemed appropriate (16 CCR sect 1821(b)(9))

9) I shall address with the intern the manner in which emergencies will be handled (16 CCR sect 1821(b)(10))

10) I agree not to provide supervision to an intern unless the intern is a volunteer or employed in a setting that meets both of the following (A)

lawfully and regularly provides mental health counseling or psychotherapy (B) provides oversight to ensure that the internrsquos work at the setting meets the experience and supervision requirements and is within the scope of practice for the profession as defined in BPC Section 499920 (BPC sect 499944)


myself and the organization in which the employer acknowledges that they are aware of the licensing requirements that must be met by the intern they agree not to interfere with my legal and ethical obligations to ensure compliance with these requirements and they agree to provide me with access to clinical records of the clients counseled by the intern (16 CCR sect 1820(e)(3))

12) I shall give at least (1) one weeks prior written notice to an intern of my intent not to sign for any further hours of experience for such person

If I have not provided such notice I shall sign for hours of experience obtained in good faith where I actually provided the required supervision (16 CCR sect 1821(d))

13) I shall obtain from each intern for whom supervision will be provided the name address and telephone number of the internrsquos most recent

supervisor and employer (16 CCR sect 1821(e)))

14) In any setting that is not a private practice I shall evaluate the site(s) where an intern will be gaining hours of experience toward licensure and shall determine that (1) the site(s) provides experience which is within the scope of practice of a licensed professional clinical counselor and (2) the experience is in compliance with the requirements set forth in 16 CCR Section 1820 and 499944 of the Code (16 CCR sect 1821(f))


forth in 16 CCR Section 1821 (16 CCR sect 1821(g))

16) I shall provide the intern with the original of this signed statement prior to the commencement of any counseling or supervision (16 CCR sect 1821(c))



_______________________________________ _____________________________________________ _______________ Printed Name of Qualified Supervisor Signature of Qualified Supervisor Date ____________________________________________________________________________________________________________________________________________

Mailing Address Number and Street City State Zip Code

The supervisor shall provide the intern being supervised with the original of this signed statement prior to the commencement of any counseling or supervision The intern shall submit this form to the board upon application for examination eligibility Licensed Clinical Psychologists and Physicians certified in psychiatry are not required to comply with 5 Applies only to supervisors NOT licensed as a Licensed Professional Clinical Counselor

37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN

Title 16 California Code of Regulations (CCR) Sections 18701 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 499623(a) 499912(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 Last

First

Middle

Registration Number

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 ( )


City State

Zip Code

Employment Setting a Private Practice a Governmental Entity b Nonprofit and Charitable Corporation c School College or University

d Licensed Health Facility e Social Rehabilitation FacilityCommunity Treatment Facility f Pediatric Day Health and Respite Care Facility g 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 supervisorrsquos 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 Supervisorrsquos Signature Date signed

Registrantrsquos Signature

Date signed

The original of this form must be submitted to the board upon application for examination eligibility

1

What to Do When the Board Requests Course Syllabi

The legislation that established licensure for Professional Clinical Counselors in California is very specific about the course content required to be provided within a qualifying degree program This requires the Board to undertake an extensive review of an applicantrsquos specific coursework when that applicantrsquos school program has not yet been evaluated by the Board The Board is unable to pre-evaluate all school programs for a variety of reasons Sometimes we do not have information about older programs or out-of-state programs or schools which have not responded to the boardrsquos request for information In the instances described above the Board will require course syllabi or other documentation in order to conduct its review of the applicantrsquos coursework It is the Boardrsquos responsibility to ensure that all applicants meet all standards required by law including course content requirements If you graduated from a school outside of California please send syllabi with your application The Board may request course syllabi from applicants with California degrees as well NOTE If your program was CACREP accredited and you graduated in 1983 or later the Board will only require syllabi for the course(s) that your school lists as fulfilling the Diagnosis core content area If you have difficulty obtaining course syllabi course descriptions from a schoolrsquos catalog may be acceptable If course descriptions are very brief the Board may require additional documentation of course content which can sometimes be provided by the school or a professor Finally if you retained any of your course assignments etc that information can also be considered

If the Board requests information about course content and you are unable to obtain ANY such documentation the Board will be unable to evaluate your education for compliance with California law and your application cannot be approved

WHAT IF MY SCHOOL HAS CLOSED

The following accreditationapproval agencies may be of assistance when trying to obtain syllabi or other course content information from a school that has closed

2

1 Western Association of Schools and Colleges (WASC)

From this agencyrsquos list of Frequently Asked Questions (FAQ) ldquoWhat happens to student records (transcripts) if a school closesrdquo

Public school records would be transferred to the district or county office of education In case of a consolidation of public schools the records may be housed at the remaining school In the case of certain religious schools that are part of a system (such as Catholic or Seventh-day Adventist schools) the records would be sent to the church headquarters For more information httpwwwwascseniororgformerlyaccredited

2 Northwest Association of Secondary and Higher Schools

Call (855) 493-5077 or email infonorthwestaccreditationorg for more information httpwwwnorthwestaccreditationorg

3 Middle States Association of Colleges and Secondary Schools

From this agencyrsquos FAQ

The closing institution arranges with the state department of higher education or other appropriate agency to file all academic records as well as financial aid information If the college merges with another institution arrangements are made with that institution to receive the records Students should receive a notice from the college about any arrangements made for filing student records

ldquoWhat Happens to Student Records When a College Closesrdquo

Sometimes students wish to know about where their records are filed long after an institution has closed In that case students should begin their inquiries by contacting the higher education agency in the state where the institution was authorized To contact this agency httpwwwmscheorg

4 New England Association of Schools and Colleges


The closing institution arranges with the state department of higher education or other appropriate agency to file all academic records as well as financial aid information You should receive a notice from the college about arrangements made for filing student records Begin further inquiries by contacting the higher education agency in the state where the institution was authorized to operate If the college merges with another institution that institution will receive the records If you need further assistance contact a member of the Commission staff To contact this agency

ldquoWhat happens to my records if my college closesrdquo

httpciheneascorg

5 North Central Association of Colleges and Secondary Schools (Higher Learning Commission) To contact this agency httpwwwncahlcorg

6 Southern Association of Colleges and Schools


Arrangements should be made with the state board for higher education or another appropriate agency for filing of student records If there is no state agency which can

Academic Records and Financial Aid Transcripts

3

receive records arrangements should be made with a state university with the state archives or with a private organization to preserve the records Notification should be sent to every current and past student indicating where the records are being stored and what the accessibility to those records will be Where possible a copy of a students record should also be forwarded to the individual student The institution must notify the Commission regarding the final filing of student records To contact this agency httpsacscocorg

7 California Bureau for Private Postsecondary Education (BPPE)

bull Student Transcripts or Student Records - For information on obtaining student

transcripts student records or to speak with the Student TranscriptsStudent Records staff member please call (888) 370-7589 press 2 when prompted

bull Student Tuition Recovery Fund and Closed Schools Unit - To obtain information on the Student Tuition Recovery Fund or Closed Schools please call (888) 370-7589 press 5 when prompted Website httpwwwbppecagov

4 lpcc_wkylog_37a-638_option1pdf

professional clinical counselor intern

5 LPCC_syllabi_infopdf

From this agencyrsquos list of Frequently Asked Questions (FAQ) UldquoWhat happens to student records (transcripts) if a school closesrdquo

From this agencyrsquos FAQ UldquoWhat Happens to Student Records When a College Closesrdquo

From this agencyrsquos FAQ UldquoWhat happens to my records if my college closesrdquo

From this agencyrsquos FAQ UAcademic Records and Financial Aid Transcripts

1b MFT weekly log - option1pdf

marriage and FAMILY THERAPIST trainee intern

2 MFT Supervisor responsibility statementpdf

Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License

Physician certified in psychiatry by the American Board of Psychiatry and Neurology

License

Issue Date

Printed Name of Qualified Supervisor Signature of Qualified Supervisor Date


3 mft expiernce chartpdf

Maximum 1000 hours

Maximum 500 hours

Trainees Minimum one (1) unit of supervision for every five (5) hours of client contact in each setting

Post-degree Minimum one (1) unit of supervision each week in each setting AND one additional unit during any week in which more than ten (10) hours of client contact is gained in each setting

(One unit of supervision is equal to one (1) hour of individual or two (2) hours of group supervision)

3 mft supervisor informationpdf

MARRIAGE AND FAMILY THERAPIST TRAINEE AND INTERN

SUPERVISION INFORMATION

General Qualifications

Six Hour Supervision Training

MFT Trainee and Intern Supervised Experience Requirements

4 mft FAQ and trainee hourspdf

1 Should I be concerned about abandonment of my application

2 Now that my Intern registration has been issued can I start practicing independently or open my own office

3 What is the breakdown for the required hours of experience to become a Licensed Marriage and Family Therapist (LMFT)

4 How far back can hours of experience be counted What is the 6-year rule

5 What types of hours can I count as a Trainee

6 Do I need to register as a Trainee with the Board

7 As a Trainee when can I begin counting pre-degree hours of work experience Must I be enrolled in practicum in order to counsel clients

8 Can I count hours of experience after I graduate but before I receive an Intern registration number

9 Can I begin work in a private practice setting without having an Intern registration number Can I work in a private practice under my second Intern registration number

10 Can I be paid as a 1099 independent contractor while a Trainee or Intern Can I be employed as a volunteer What type of documentation does the Board require

11 Do I need to send in originals of my W-2s or most recent pay stub with my Examination Eligibility Application

12 How do I determine the amount of supervision I need each week What is the difference between the supervision requirements for MFT Trainees and Interns What is the required ratio of supervision to client contact hours

16 How many supervisees can participate in a session of group supervision

17 Can group supervision be broken into one-hour increments

18 Can I receive supervision via videoconferencing or over the telephone

19 Do my supervisor and I have to be employed by the same employer Does my supervisor need to be on site

20 Where do I record Personal Psychotherapy hours Irsquove received Must I be under supervision while receiving Personal Psychotherapy

13 When I submit my Examination Eligibility Application do I need to separate hours gained pre-degree from hours gained post-degree Do I need to separate hours gained prior to 01012010 and hours gained on or after 01012010 What about hours g

14 Who can supervise MFT Trainees or Interns

21 What is the definition of ldquotelehealth counselingrdquo

22 What additional coursework do I need to complete Must I complete this coursework prior to submitting my Intern application

23 When do I need to send in supervision-related forms

24 How can I provide verification of my experience if my supervisor can no longer be located

25 Do I need to resubmit fingerprints with my Examination Eligibility Application or for a subsequent Intern registration number

26 What happens once I submit my ldquoExamination Eligibilityrdquo Application

27 Do I need to maintain a current Intern registration number to participate in the examinations

28 Must I continue to have supervision while in the exam process

29 Once I pass my exams can I start practicing independently

4 mft_supervision_brochurepdf




Your Supervisorrsquos License Status

Your Registrationrsquos Status

Complaints Against a Supervisor

4a lpc_supervisor responsibility statementpdf

Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License

Licensed Physician and Surgeon who is certified in psychiatry by the

American Board of Psychiatry and Neurology

License

Issue Date





Instructions to student and placement coordinator This form should be completed in consultation after the SJSU student has received verbal site approval from the fieldwork coordinator Name _______________________________________ Phone ___________________ Address __________________________________________________________________ Agency Information Placement ___________________________________ Phone ___________________ Placement Address _________________________________________________________ Name of Supervisor ___________________________ Phone ___________________ Supervisor Credentials Degree _________ Date Degree Granted ________ Institution ______________________ License ________ Year Granted _________ Years of Supervisory Experience ________ Clinical Responsibilities and Training

1 Supervision Format(s) (Individual Group etc) ______________________________

2 _____ hour(s) of individual supervision each week per _____ client contact hours

3 Theoretical Orientation of the Supervisor ___________________________________ Clinical Responsibilities and Training

1 Clientele served by the agency ___________________________________________

2 Description of clinical problems trainee is likely to address _____________________

____________________________________________________________________ ____________________________________________________________________

Continued on other side





























hours were earned










click






Free Trial


Log In Free Trial















Summary Report






13

13





















From BBS


























New Law




Activities





Previous Law






































1250 hours Max 1000

hours
















37A-525 (Revised 052016)


















Supe

rvis

or

Sign

atur

e




37A-523 (Rev 310) 1











License Issue Date


License Issue Date












37A-523 (Rev 310) 2
























MIS

CELL

AN

EOU

S D

IREC

T CO

UN

SELI

NG










combination of both



Revised 112


Revised 112


SUPE

RVIS

ION













TOTA

LS








37M-803 (Rev 111)




























































Stay Informed






(Revised 052016)



MFT Interns













MFT Trainees










13



13


13

13






Degree Requirements












Hours of Experience






EXAMINATIONS












APPLICATION PACKETS

























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date































hours were earned










click






Free Trial


Log In Free Trial















Summary Report






13

13





















From BBS


























New Law




Activities





Previous Law






































1250 hours Max 1000

hours
















37A-525 (Revised 052016)


















Supe

rvis

or

Sign

atur

e




37A-523 (Rev 310) 1











License Issue Date


License Issue Date












37A-523 (Rev 310) 2
























MIS

CELL

AN

EOU

S D

IREC

T CO

UN

SELI

NG










combination of both



Revised 112


Revised 112


SUPE

RVIS

ION













TOTA

LS








37M-803 (Rev 111)




























































Stay Informed






(Revised 052016)



MFT Interns













MFT Trainees










13



13


13

13






Degree Requirements












Hours of Experience






EXAMINATIONS












APPLICATION PACKETS

























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date

















Summary Report






13

13





















From BBS


























New Law




Activities





Previous Law






































1250 hours Max 1000

hours
















37A-525 (Revised 052016)


















Supe

rvis

or

Sign

atur

e




37A-523 (Rev 310) 1











License Issue Date


License Issue Date












37A-523 (Rev 310) 2
























MIS

CELL

AN

EOU

S D

IREC

T CO

UN

SELI

NG










combination of both



Revised 112


Revised 112


SUPE

RVIS

ION













TOTA

LS








37M-803 (Rev 111)




























































Stay Informed






(Revised 052016)



MFT Interns













MFT Trainees










13



13


13

13






Degree Requirements












Hours of Experience






EXAMINATIONS












APPLICATION PACKETS

























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date




13

13





















From BBS


























New Law




Activities





Previous Law






































1250 hours Max 1000

hours
















37A-525 (Revised 052016)


















Supe

rvis

or

Sign

atur

e




37A-523 (Rev 310) 1











License Issue Date


License Issue Date












37A-523 (Rev 310) 2
























MIS

CELL

AN

EOU

S D

IREC

T CO

UN

SELI

NG










combination of both



Revised 112


Revised 112


SUPE

RVIS

ION













TOTA

LS








37M-803 (Rev 111)




























































Stay Informed






(Revised 052016)



MFT Interns













MFT Trainees










13



13


13

13






Degree Requirements












Hours of Experience






EXAMINATIONS












APPLICATION PACKETS

























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date























From BBS


























New Law




Activities





Previous Law






































1250 hours Max 1000

hours
















37A-525 (Revised 052016)


















Supe

rvis

or

Sign

atur

e




37A-523 (Rev 310) 1











License Issue Date


License Issue Date












37A-523 (Rev 310) 2
























MIS

CELL

AN

EOU

S D

IREC

T CO

UN

SELI

NG










combination of both



Revised 112


Revised 112


SUPE

RVIS

ION













TOTA

LS








37M-803 (Rev 111)




























































Stay Informed






(Revised 052016)



MFT Interns













MFT Trainees










13



13


13

13






Degree Requirements












Hours of Experience






EXAMINATIONS












APPLICATION PACKETS

























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date
























New Law




Activities





Previous Law






































1250 hours Max 1000

hours
















37A-525 (Revised 052016)


















Supe

rvis

or

Sign

atur

e




37A-523 (Rev 310) 1











License Issue Date


License Issue Date












37A-523 (Rev 310) 2
























MIS

CELL

AN

EOU

S D

IREC

T CO

UN

SELI

NG










combination of both



Revised 112


Revised 112


SUPE

RVIS

ION













TOTA

LS








37M-803 (Rev 111)




























































Stay Informed






(Revised 052016)



MFT Interns













MFT Trainees










13



13


13

13






Degree Requirements












Hours of Experience






EXAMINATIONS












APPLICATION PACKETS

























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date

































1250 hours Max 1000

hours
















37A-525 (Revised 052016)


















Supe

rvis

or

Sign

atur

e




37A-523 (Rev 310) 1











License Issue Date


License Issue Date












37A-523 (Rev 310) 2
























MIS

CELL

AN

EOU

S D

IREC

T CO

UN

SELI

NG










combination of both



Revised 112


Revised 112


SUPE

RVIS

ION













TOTA

LS








37M-803 (Rev 111)




























































Stay Informed






(Revised 052016)



MFT Interns













MFT Trainees










13



13


13

13






Degree Requirements












Hours of Experience






EXAMINATIONS












APPLICATION PACKETS

























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date



37A-525 (Revised 052016)


















Supe

rvis

or

Sign

atur

e




37A-523 (Rev 310) 1











License Issue Date


License Issue Date












37A-523 (Rev 310) 2
























MIS

CELL

AN

EOU

S D

IREC

T CO

UN

SELI

NG










combination of both



Revised 112


Revised 112


SUPE

RVIS

ION













TOTA

LS








37M-803 (Rev 111)




























































Stay Informed






(Revised 052016)



MFT Interns













MFT Trainees










13



13


13

13






Degree Requirements












Hours of Experience






EXAMINATIONS












APPLICATION PACKETS

























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date



37A-523 (Rev 310) 1











License Issue Date


License Issue Date












37A-523 (Rev 310) 2
























MIS

CELL

AN

EOU

S D

IREC

T CO

UN

SELI

NG










combination of both



Revised 112


Revised 112


SUPE

RVIS

ION













TOTA

LS








37M-803 (Rev 111)




























































Stay Informed






(Revised 052016)



MFT Interns













MFT Trainees










13



13


13

13






Degree Requirements












Hours of Experience






EXAMINATIONS












APPLICATION PACKETS

























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date



37A-523 (Rev 310) 2
























MIS

CELL

AN

EOU

S D

IREC

T CO

UN

SELI

NG










combination of both



Revised 112


Revised 112


SUPE

RVIS

ION













TOTA

LS








37M-803 (Rev 111)




























































Stay Informed






(Revised 052016)



MFT Interns













MFT Trainees










13



13


13

13






Degree Requirements












Hours of Experience






EXAMINATIONS












APPLICATION PACKETS

























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date




MIS

CELL

AN

EOU

S D

IREC

T CO

UN

SELI

NG










combination of both



Revised 112


Revised 112


SUPE

RVIS

ION













TOTA

LS








37M-803 (Rev 111)




























































Stay Informed






(Revised 052016)



MFT Interns













MFT Trainees










13



13


13

13






Degree Requirements












Hours of Experience






EXAMINATIONS












APPLICATION PACKETS

























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date




Revised 112


SUPE

RVIS

ION













TOTA

LS








37M-803 (Rev 111)




























































Stay Informed






(Revised 052016)



MFT Interns













MFT Trainees










13



13


13

13






Degree Requirements












Hours of Experience






EXAMINATIONS












APPLICATION PACKETS

























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date



37M-803 (Rev 111)




























































Stay Informed






(Revised 052016)



MFT Interns













MFT Trainees










13



13


13

13






Degree Requirements












Hours of Experience






EXAMINATIONS












APPLICATION PACKETS

























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date











































Stay Informed






(Revised 052016)



MFT Interns













MFT Trainees










13



13


13

13






Degree Requirements












Hours of Experience






EXAMINATIONS












APPLICATION PACKETS

























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date





MFT Interns













MFT Trainees










13



13


13

13






Degree Requirements












Hours of Experience






EXAMINATIONS












APPLICATION PACKETS

























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date











13



13


13

13






Degree Requirements












Hours of Experience






EXAMINATIONS












APPLICATION PACKETS

























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date








Degree Requirements












Hours of Experience






EXAMINATIONS












APPLICATION PACKETS

























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date










APPLICATION PACKETS

























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date


























13
































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date


































2 of 2























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date

























1250 hours Max 1000

hours
















37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date



37A-638 (052016)










Yes No










Supe

rvis

or

Sign

atur

e















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date















License Issue Date













37A-643 (new 310) 1






















37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date
























37A-643 (new 310) 2

37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date



37A-521 (Rev310)




SUPERVISORY PLAN


Legal name Last

First

Middle

Registration Number


City State

Zip Code

Business Telephone

( )

Residence Telephone


Last


Employer Name



City State

Zip Code





Date signed


1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date



1






2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date



2















httpciheneascorg






3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date



3
















Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License


License

Issue Date




Maximum 1000 hours

Maximum 500 hours















































Issue Date

License

Issue Date

License

Issue Date

License

Issue Date

License



License

Issue Date

