Fill - Free fillable APPLICATION FOR LICENSURE OUT-OF-STATE LICENSED MARRIAGE AND FAMILY (California) PDF form

STATE OF CALIFORNIA – BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY Gavin Newsom, Governor

Board of Behavioral Sciences

1625 North Market Blvd., Suite S200, Sacramento, CA 95834

(916) 574-7830

www.bbs.ca.gov

LICENSED MARRIAGE AND FAMILY THERAPIST

OUT-OF-STATE

APPLICATION FOR LICENSURE

For applicants with an out-of-state degree or license*

Dear Out-of-State Applicant:

Thank you for your interest in becoming a California Licensed Marriage and Family

Therapist. Included in this packet are the following forms and documents:

1. Guide to Out-of-State Applicant Requirements

2. Application Instructions

3. Important Information for Applicants

4. Out-of-State Application for LMFT Licensure – GENERAL

5. Application for Licensure PATH A - BY CREDENTIAL

6. Application for Licensure PATH B - BY EDUCATION AND EXPERIENCE

7. Out-of-State License or Registration Verification Form

8. Out-of-State Experience Verification Form

9. Out-of-State Degree Program Certification Form

10. Instructions for Live Scan Fingerprinting/Request for Live Scan Service Form

BOARD OF BEHAVIORAL SCIENCES

*If you are not licensed in another state but have an Out-of-State

degree, and are currently registered as an Associate in California

and have gained experience hours in California, you may instead

submit an In-State Application for Licensure

. You may have

coursework to complete - please refer to the notice sent upon

approval of your Associate application.

37A-642 (Revised 01/2021) 1

GUIDE TO LMFT OUT-OF-STATE

APPLICANT REQUIREMENTS

Applicant Type

Do you meet ALL of the following requirements?

 I have held a license as a Marriage and Family Therapist in another United States

jurisdiction for at least two years.

 The license I hold is current, and has been active and unrestricted for at least two

years immediately before the date I submit my application to the Board.

 The license I hold is at the highest level for independent clinical practice in that

jurisdiction.

 The degree that qualified me for this license is a master’s or doctoral degree obtained

from a school holding a regional or national institutional accreditation recognized by the

U.S. Department of Education (USDE), or a school approved by the California Bureau

for Private Postsecondary Education (BPPE).

If YES, go to Path A (LICENSURE BY CREDENTIAL)

If NO,



Skip to Path B (LICENSURE BY EDUCATION/EXPERIENCE)

Path A – LICENSURE BY CREDENTIAL

Applicants who qualify for this path (as specified in Business and Professions Code

(BPC) section 4980.72) must meet all of the following requirements. See the Application

for Licensure – Out-of-State for details.

1. EXAMINATION: You must pass the California Law and Ethics Examination. You will

be eligible to take this exam after your Application for Licensure has been approved.

2. QUALIFYING DEGREE: The degree that qualified you for licensure in another

United States jurisdiction must be a master’s or doctoral degree obtained from a

school that holds a regional or national institutional accreditation recognized by the

USDE, or a school approved by the BPPE.

3. COURSEWORK: You must complete the following California-specific coursework.

Courses must be taken from a school that holds a regional or national institutional

accreditation recognized by the USDE, a school approved by the BPPE, or an

acceptable continuing education provider. Undergraduate coursework cannot be

accepted.

37A-642 (Revised 01/2021) 2

Path A – LICENSURE BY CREDENTIAL (continued)

REQUIRED CALIFORNIA-SPECIFIC COURSEWORK

Course

Length

Content Required

California Law and Ethics

12 hours Instruction must include advertising, scope of

practice, scope of competence, treatment of minors,

confidentiality, dangerous patients, psychotherapist-

patient privilege, recordkeeping, patient access to

records, state and federal laws relating to

confidentiality of patient health information, dual

relationships, child abuse, elder and dependent

adult abuse, online therapy, insurance

reimbursement, civil liability, disciplinary actions and

unprofessional conduct, ethics complaints and

ethical standards, termination of therapy, standards

of care, relevant family law, therapist disclosures to

patients, the application of legal and ethical

standards in different types of work settings, and

licensing law and licensing process. See

BPC

section 4980.72.

California Cultures and the

Social and Psychological

Implications of

Socioeconomic Position

15 hours or 1

semester unit

Instruction must include an understanding of various

California cultures and the social and psychological

implications of socioeconomic position. See

BPC

section 4980.72.

Child Abuse Assessment and

Reporting in California

(In addition to the course provider

types listed above, this may be a

course sponsored or offered by a

professional association or a local,

county or state department of

health or mental health)

7 hours Instruction must include detailed knowledge of the

California Child Abuse Neglect and Reporting Act

(CANRA). It must also include assessment and

methods of reporting of sexual assault, neglect,

severe neglect, general neglect, willful cruelty or

unjustifiable punishment, corporal punishment or

injury, and abuse in out-of-home care. The training

shall also include physical and behavioral indicators

of abuse, crisis counseling techniques, community

resources, rights and responsibilities of reporting,

consequences of failure to report, caring for a

child’s needs after a report is made, sensitivity to

previously abused children and adults, and

implications and methods of treatment for children

and adults. See BPC sections 28 and 4980.72

Suicide Risk Assessment

and Intervention

(Does not need to be California-

specific)

6 hours of

coursework

or applied

experience

• See BPC section 4980.396

for details.

Note: 1 semester unit = 15 hours; 1 quarter unit = 10 hours

1 semester unit = 1.5 quarter units

37A-642 (Revised 01/2021) 3

Path B – LICENSURE BY EDUCATION/EXPERIENCE

Applicants who do not qualify for Path A “Licensure by Credential” must meet the

following requirements as specified in Business and Professions Code (BPC) sections

4980.74, 4980.78 and 4980.81. See the Application for Licensure – Out-of-State for

more details.

1. EXAMINATIONS: You must pass both of the following exams:

• California Law and Ethics Exam: You will be eligible to take this exam after

issuance of your Associate number or after approval of your Application for

Licensure.

• California LMFT Clinical Exam: You will be eligible to take this exam after

approval of your Application for Licensure and after passing the California Law

and Ethics Exam.

2. SUPERVISED EXPERIENCE: Your experience must be substantially equivalent

to California’s requirements as described below.

• If you are licensed as an LMFT in another state or country at the highest

level for independent clinical practice: Your requirements will depend on

whether you were licensed at the highest level for independent clinical practice

in a jurisdiction of the United States vs. another country. It will also depend on

how many hours were required for that license by the other state or country, as

described below:

o If you are licensed in another United States jurisdiction that requires at

least 3,000 hours of experience: You do not need to submit verification of

your experience.

o If you are licensed in another country: You must submit verification of

3,000 hours of substantially equivalent experience that includes 104

supervised weeks.

o If you are licensed in another state or country that requires less than 3,000

hours of experience: You may make up the deficit using time actively

licensed in good standing in another state or country at the rate of 100

hours per month licensed at the highest level (up to a maximum of 1,200

hours). You do not need to submit verification of these hours.

If additional hours are needed and will be gained in California, you must first

California.

• All other applicants: You must submit verification of substantially equivalent

supervised experience totaling 3,000 hours as described below:

37A-642 (Revised 01/2021) 4

Path B – LICENSURE BY EDUCATION/EXPERIENCE (continued)

For questions about supervised experience requirements, contact: bbs.lmft@dca.ca.gov

3. QUALIFYING DEGREE: Your degree must be a master’s or doctoral degree

obtained from a school that holds a regional or national institutional accreditation

recognized by the USDE, or a school approved by the BPPE. If your degree was

obtained outside of the United States, you must obtain a degree evaluation in

accordance with BPC section 4980.76. See Summary of LMFT Out-of-State

Education Requirements on the next page for other minimum degree

requirements.

4. DEGREE REMEDIATION: You must remediate any deficiencies in your degree

program where allowed as specified in BPC section 4980.78. See the chart on the

next page for a summary, and the Application for Licensure for details.

5. ADDITIONAL COURSEWORK: You must complete coursework in accordance

with BPC sections 4980.78 and 4980.81, some of which must be California-

specific. See the chart beginning on page 6 for details. Courses may be taken from

a school that holds a regional or national institutional accreditation recognized by

the USDE, a school approved by the BPPE, or an acceptable continuing education

provider. Undergraduate coursework cannot be accepted. If it will take you a

significant amount of time to complete your coursework, you may want to consider

registering as an Associate while you are taking the courses as it will allow you to

work as a therapist in California under supervision.

If you are unsure whether your degree or coursework qualifies (or is deficient), submit

your Associate Marriage and Family Therapist Registration Application or Application

for Licensure and fee, and we will provide you with the results of the evaluation.

For questions about educational requirements, contact: bbs.amft@dca.ca.gov

• Experience must have been supervised by a licensed mental health

professional.

• Experience must have been gained within the six (6) years prior to the

Board’s receipt of your California application.

• Up to 1,300 hours may have been gained prior to the issuance of y our

qualifying degree.

• If you are not licensed in another state or country at the highest level f or

independent clinical practice, you must have 104 weeks of supervision.

• If any experience will be obtained in California, you must first register as

an Associate and comply with all requirements for hours gained in

California.

37A-642 (Revised 01/2021) 5

Summary of LMFT Out-of-State Education Requirements & Remediation

Path B – LICENSURE BY EDUCATION/EXPERIENCE

1. OVERALL

DEGREE

UNITS

Degree program began

prior to 8/1/2012

Degree program began

after 8/1/2012

5. ADDITIONAL COURSEWORK

Must remediate prior to approval of

Application for Licensure. Required

courses listed on the following pages.

4. MARITAL AND FAMILY

COUNSELING/SYSTEMS APPROACH

12 semester units or 18 quarter units

within degree or cannot qualify

2. CALIFORNIA LAW

AND ETHICS

(L&E) COURSE

(see BPC section

4980.78(b)(2) for

course content

requirements)

Completed a 2 semester

unit or 3 quarter unit L&E

course but no California

content

No L&E course or course is

short units

12-hour California L&E course prior to

issuance of Associate registration

2 semester unit or 3 quarter unit

California L&E course prior to issuance of

Associate registration

3. PRACTICUM

• 6 semester or 9

quarter units and

• 225 hours of

supervised face-to-

face counseling

experience (up to

75 hours may be

client-centered

advocacy)

Holds a valid license in

good standing in another

state or country as an

MFT at the highest level

for independent clinical

practice

All Others

Practicum requirement waived

Degree program must meet practicum

unit/hour requirements or cannot

qualify

Minimum 48 semester units or 72 quarter units

within degree or cannot qualify

•

Minimum 48 semester or 72 quarter units

within degree or cannot qualify

• Must complete 60 semester units or 90 quarter

units total

• Must remediate prior to approval of Licensing

application

37A-642 (Revised 01/2021) 6

5. ADDITIONAL COURSEWORK

LMFT Out-of-State Applicants

Path B – LICENSURE BY EDUCATION/EXPERIENCE

Note: 1 semester unit = 15 hours; 1 quarter unit = 10 hours

1 semester unit = 1.5 quarter units

Course

Length

Content Required

a) Suicide Risk Assessment and

Intervention

6 hours of

coursework

or applied

experience

See BPC section 4980.396

b) Mental Health Recovery

Oriented Care and Methods of

Service Delivery

45 hours or

3 semester

units

Instruction must cover principles of mental health

recovery-oriented care and methods of service delivery

in recovery-oriented practice environments, including

structured meetings with various consumers and family

members of consumers of mental health services to

enhance understanding of their experience of mental

illness, treatment and recovery. See

BPC section

4980.81.

c) California Cultures and the

Social and Psychological

Implications of Socioeconomic

Position

15 hours or

1 semester

unit

Instruction must include an understanding of various

California cultures and the social and psychological

implications of socioeconomic position. See

BPC

section 4980.81.

d) Diagnosis, Assessment,

Prognosis and Treatment of

Mental Disorders

2 semester

units

Must include diagnosis, assessment, prognosis and

treatment of mental disorders, including:

• Severe mental disorders

• Promising mental health practices

• Evidence-based practices

See BPC section 4980.81

e) Psychological Testing 15 hours or

1 semester

unit

Instruction must cover psychological testing. See BPC

section 4980.81.

f) Psychopharmacology 15 hours or

1 semester

unit

Instruction must cover psychopharmacology. See BPC

section 4980.81.

37A-642 (Revised 01/2021) 7

5. ADDITIONAL COURSEWORK

(continued)

LMFT Out-of-State Applicants

Path B – LICENSURE BY EDUCATION/EXPERIENCE

Course

Length

Content Required

g) Developmental Issues from

Infancy to Old Age

15 hours or

1 semester

unit

(if deficient

in a single

topic listed,

may

remediate

by taking 3

hours of

instruction

on each

missing

topic)

Instruction must include:

• Developmental Issues from infancy to old age

• The effects of developmental issues on

individuals, couples and family relationships.

• The psychological, psychotherapeutic, and health

implications of developmental issues and their

effects.

• The understanding of the impact that personal and

social insecurity, social stress, low educational

levels, inadequate housing and malnutrition have

on human development.

See BPC section 4980.81

h) Child Abuse Assessment and

Reporting in California

7 hours Instruction must include detailed knowledge of the

California Child Abuse Neglect and Reporting Act

(CANRA). It must also include assessment and

methods of reporting of sexual assault, neglect, severe

neglect, general neglect, willful cruelty or unjustifiable

punishment, corporal punishment or injury, and abuse

in out-of-home care. The training shall also include

physical and behavioral indicators of abuse, crisis

counseling techniques, community resources, rights

and responsibilities of reporting, consequences of

failure to report, caring for a child’s needs after a report

is made, sensitivity to previously abused children and

adults, and implications and methods of treatment for

children and adults. See

BPC sections 28 and 4980.81

and Title 16, California Code of Regulations section

1807.2

i) Aging, Long Term Care and

Elder/Dependent Adult Abuse,

End-of-Life and Grief

10 hours Instruction must cover aging and long-term care,

including biological, social, cognitive and psychological

aspects of aging, end-of-life, grief, and instruction on

the assessment and reporting of, as well as treatment

related to, elder and dependent adult abuse and

neglect. See BPC section 4980.81

j) Spousal/Partner Abuse

Assessment, Detection and

Intervention

15 hours Instruction must cover spousal and partner abuse

assessment, detection, intervention strategies, and

same-gender abuse dynamics. See

BPC section

4980.81.

37A-642 (Revised 01/2021) 8

5. ADDITIONAL COURSEWORK (continued)

LMFT Out-of-State Applicants

Path B – LICENSURE BY EDUCATION/EXPERIENCE

Course

Length

Content Required

k) Multicultural Development and

Cross-Cultural Interaction

15 hours or

1 semester

unit

Instruction must include experiences of race, ethnicity,

class, spirituality, sexual orientation, gender, and

disability, and their incorporation into the

psychotherapeutic process. See BPC section 4980.81

l) Human Sexuality 10 hours Instruction must include the study of the physiological,

psychological, and social cultural variables associated

with sexual behavior, gender identity, and the

assessment and treatment of psychosexual

dysfunction. See

BPC sections 25 and 4980.81 and

Title 16, California Code of Regulations section 1807

m) Substance Use Disorders 15 hours See BPC section 4980.81.

n) Co-Occurring Disorders and

Addiction

15 hours See BPC section 4980.81.

o) Miscellaneous Content No specific

number of

hours

required,

but content

must be

adequately

covered

within the

applicant’s

coursework

Instruction must include:

• Childbirth, child rearing, parenting and step-

parenting

• Marriage, divorce and blended families

• Cultural factors relevant to abuse of partners and

family members

• Poverty and deprivation

• Financial and social stress

• Effects of trauma

• The psychological, psychotherapeutic, community

and health implications of the matters and life

events that arise in marriage and family

relationships within a variety of California cultures

See BPC section 4980.81

37A-319 (Revised 01/2021) 1

APPLICATION FOR LICENSURE

LICENSED MARRIAGE

AND FAMILY THERAPIST

Out-of-State Applicant

Application Instructions

Read Carefully Before Completing Your Application

Submit your completed application to: Board of Behavioral Sciences

1625 North Market Blvd., Suite S200

Sacramento, CA 95834

EXPEDITED REVIEW

The Board is required to expedite the licensure process for the following applicants:

• Honorably discharged veterans of the U.S. Armed Forces pursuant to Business and

Professions Code (BPC) section 115.4. Download the request form from the Board’s

website and include it ON TOP OF your application.

• Spouses/Partners of persons on active duty military pursuant to BPC section 115.5.

Download the request form from the Board’s website and include it ON TOP OF your

application.

• Refugees / Asylees / Special Immigrant Status Holders ("SI" or "SQ") pursuant to BPC

section 135.4. Download the request form from the Board’s website and include it ON TOP

OF your application.

PROOF OF RECEIPT OF APPLICATION

If you would like to know whether the Board has received your application, you will need to mail

your application using a service that includes tracking. You can also check with your bank to see if

your check or money order has been cashed by the Board.

Carefully read all instructions to ensure an accurate and complete application package and

that all required original documents are furnished to the Board.

All items are mandatory unless otherwise indicated.

Any omission may result in your application being deficient or delayed.

37A-319 (Revised 01/2022) 2

REQUIREMENTS FOR ALL APPLICANTS

A. GENERAL APPLICATION

Instructions Document(s) Required

• Complete all sections of the Application for Licensure – General

Application in ink.

• The application must have your original signature.

• You must use your legal name. Your “legal name” is the name

established legally by your birth certificate, marriage or domestic

partnership certificate, or divorce decree (for example).

• Name Change: If you have registered with the Board previously

and have changed your legal name without notifying the Board,

submit a Notification of Name Change form with your application

packet along with the required documentation.

• Email Address: Provide an email address if you have one. This

address is not subject to public disclosure.

Completed and signed

General Application

37A-319 (Revised 01/2022) 3

B. FEES

Instructions Document(s) Required

Carefully read the information below to determine the fees

required. Incorrect submission will delay your application.

f you need clarification, contact bbs.lmft@dca.ca.gov

prior to

submission.

1. Applicants who have NEVER been issued a registration or

license with the BBS and are applying under PATH A or B:

Attach a $400.00 check or money order to your Application for Licensure

– General Application, made payable to the Behavioral Sciences Fund.

The $400.00 fee consists of a $250.00 application fee and a $150.

alifornia Law and Ethics Exam fee. The application fee is an earned f

or evaluation of your application and is NOT REFUNDABLE.

2. Applicants who HAVE been issued a registration or license

with the BBS at any time in the past and are applying under

PATH A (Licensure by Credential):

Attach a $250.00 check or money order to your Application for Licensure

– General Application, made payable to the Behavioral Sciences Fund.

This is an earned fee for evaluation of your application and is NOT

REFUNDABLE.

3. Applicants who HAVE been issued a registration or license

with the BBS at any time in the past, and are applying under

PATH B (Licensure by Education/Experience):

Attach a $500.00 check or money order to your Application for Licensure

- General Application, made payable to the Behavioral Sciences Fund.

The $500.00 fee consists of a $250.00 application fee and a $250.

Cli

nical Exam fee. The application fee is an earned fee for evaluation of

your application and is NOT REFUNDABLE.

1. A $400.00 check or

money order payable

to the Behavioral

Sciences Fund,

attached to your

General Application

2. A $250 check or

money order payable

to the Behavioral

Sciences Fund,

attached to your

General Application

3. A $500 check or

money order

payable to the

Behavioral Sciences

Fund, attached to

your General

Application

37A-319 (Revised 01/2022) 4

REQUIREMENTS FOR ALL APPLICANTS (CONTINUED)

C. FINGERPRINTS

Instructions Document(s) Required

Disregard this section if you are currently registered with the BBS as an

Associate

The Board requires a Department of Justice (DOJ) and Federal Bureau

of Investigation (FBI) criminal history background check on all applicants.

If you currently reside in California: Read the Instructions for Live

Scan Fingerprinting and complete the Request for Live Scan Service

form included in this application packet.

• The information on this form must match the information you

provide on your application.

• DO NOT COMPLETE FINGERPRINTS MORE THAN 60 DAYS

PRIOR TO SUBMITTING YOUR APPLICATION. Fingerprint results

without an application on file will only be held for 6 months.

If you currently reside out of state: You must use the "hard card"

fingerprint method unless you can access a California Live Scan

Service operator. To request fingerprint hard cards, send an email to

BBS.Fingerprint@dca.ca.gov with "Fingerprint Hard Cards" in the

subject line, and we will mail them to you.

• DO NOT SUBMIT YOUR FINGERPRINTS TO THE BOARD UNTIL

YOU HAVE SUBMITTED YOUR APPLICATION – we are unable to

process them until your application is received.

• Note: The DOJ processing time for hard card fingerprints is a

minimum of 8 weeks.

If you currently reside in

California: Submit the

second copy of your

completed Request for

Live Scan Service

Applicant Submission

form.

If you currently reside

out of state:

Submit two completed

fingerprint hard cards

(FBI and DOJ)

D. VERIFICATION OF LICENSE/REGISTRATION IN ANOTHER STATE OR COUNTRY

Instructions Document(s) Required

Include certified statement(s) from each state or country where you hold

or have held a license or registration to practice marriage and family

therapy. This verification may be provided in one of the following ways:

• Emailed to the Board directly from the other state to

BBSLicCerts@dca.ca.gov

• Sent to the Board directly from the other state IN AN ENVELOPE

SEALED BY THE STATE LICENSING AGENCY.

Enclosed with the application IN AN ENVELOPE SEALED BY

THE STATE LICENSING AGENCY.

Verification of licensure

or registration emailed

or sent to the Board in

a SEALED ENVELOPE

OR EMAILED AS

DIRECTED

37A-319 (Revised 01/2022) 5

LICENSURE PATHWAY REQUIREMENTS

This section will help you determine your specific application,

education, experience and examination requirements.

Path A – LICENSURE BY CREDENTIAL

You may qualify for Path A – Licensure by Credential if you meet ALL of the

following requirements:

 I have held a license as a Marriage and Family Therapist in another United States

jurisdiction for at least two years.

 The license I hold is current, and has been active and unrestricted for at least two years

immediately before the date I submit my application to the Board.

 The license I hold is at the highest level for independent clinical practice in that jurisdiction.

 The degree that qualified me for this license is a master’s or doctoral degree obtained from

a school holding a regional or national institutional accreditation recognized by the U.S.

Department of Education (USDE), or a school approved by the California Bureau for

Private Postsecondary Education (BPPE).

If you do NOT meet ALL of the above requirements:

You do NOT qualify for LICENSURE BY CREDENTIAL

 Skip to Path B:

LICENSURE BY EDUCATION AND EXPERIENCE (Page 6)

If you DO meet ALL of the above requirements:

You must comply with Path A:

LICENSURE BY CREDENTIAL

37A-319 (Revised 01/2021) 6

Path A – LICENSURE BY CREDENTIAL

1. APPLICATION FOR PATH A

Instructions Document(s) Required

Submit an Application for Path A - Licensure by Credential. Must have

an original signature.

Application for Path A

2. CALIFORNIA LAW AND ETHICS EXAMINATION

Instructions Document(s) Required

You must pass the California Law and Ethics Examination. You will be

eligible to take this exam after your application has been approved.

You will be provided with information on how to register at that time.

None at this time

3. QUALIFYING DEGREE

Instructions Document(s) Required

Provide official transcript(s) verifying your qualifying master’s or doctoral

degree with degree title and date of conferral posted as directed below:

• Mailed to the Board IN AN ENVELOPE SEALED BY THE

EDUCATIONAL INSTITUTION; or

• Sent electronically BY YOUR SCHOOL to the Board at

BBSLMFTtranscripts@dca.ca.gov (for questions see FAQ).

Note: The degree that qualified you for licensure in another United

States jurisdiction must be a master’s or doctoral degree obtained from

a school that holds a regional or national institutional accreditation

recognized by the U.S. Department of Education or a school approved

by the California Bureau for Private Postsecondary Education.

Otherwise, you must apply under “Licensure by Education and

Experience” (See Path B).

Official transcript(s)

with degree title and

date of conferral

posted.

MUST BE SENT

ELECTRONICALLY BY

SCHOOL OR MAILED

IN A SEALED

ENVELOPE AS

DIRECTED

4. COURSEWORK

Instructions Document(s) Required

You must complete the California-specific coursework listed in Part A

of the Guide to LMFT Out-of-State Applicant Requirements.

Proof of completion of

all required courses

5. APPLY FOR INITIAL LICENSE ISSUANCE

Instructions Document(s) Required

Upon meeting all requirements for licensure, you must submit

a Request for Initial License Issuance and fee. Do not submit

at this time – it will be rejected.

AFTER you pass the Law and

Ethics Exam, submit a Request for

Initial License Issuance and fee

37A-319 (Revised 01/2022) 7

Path B – LICENSURE BY EDUCATION AND EXPERIENCE

Applicants who do not qualify for LICENSURE BY CREDENTIAL must meet ALL

of the following requirements in order to become licensed in California:

1. APPLICATION FOR PATH B

Instructions Document(s) Required

Submit Application for Path B - Licensure by Education and

Experience. Must have an original signature.

Application for Path B

2. EXAMINATIONS

Instructions Document(s) Required

You must pass the California Law and Ethics Examination and the

California LMFT Clinical Examination. You will be eligible to take your

initial exam after your Application for Licensure has been approved.

You will be provided with information on how to register at that time.

None at this time

3. SUPERVISED EXPERIENCE

Determine Your Requirements Requirement

 I am licensed at the highest level for independent clinical practice

in another state or country that requires at least 3,000 hours of

supervised experience OR

 I am licensed in another state or country that requires less than

3,000 hours of supervised experience and I am making up the

deficit using time licensed as an MFT at the highest level for

independent clinical practice (maximum 1,200 hours).

You are not required to

provide verification of

experience. Skip to # 4

(Degree Requirements

and Remediation).

 I am licensed in another state or country that requires less than

3,000 hours of supervised experience and I am making up the

deficit using time licensed as an MFT at the highest level for

independent clinical practice, but it is not enough to total 3,000

hours OR

 I am not licensed in another state or country at the highest level for

independent clinical practice.

You are required to

provide verification of

experience so that you

reach a total of 3,000

hours. Your specific

requirements are

described below.

37A-319 (Revised 01/2022) 8

Path B – LICENSURE BY EDUCATION AND EXPERIENCE

3. SUPERVISED EXPERIENCE (continued)

Instructions for Applicants Who Must Submit Verification of Experience Document(s) Required

You must submit verification of substantially equivalent supervised

experience totaling 3,000 hours as described below:

• Experience must have been supervised by a licensed mental health

professional.

• Experience must have been gained within the six (6) years prior to

the Board’s receipt of your California application.

• Up to 1,300 hours may have been gained prior to the issuance of

your qualifying degree.

• Any hours gained in California must be while registered as an

Associate.

• If you are not licensed in another state or country at the highest level

for independent clinical practice, you must have 104 weeks of

supervision.

Experience Gained OUTSIDE of California:

• Each supervisor’s license must be verified using one of the methods

below (see attached Verification of Licensure in Another State form):

o Emailed to the Board directly from the other state to

BBSLicCerts@dca.ca.gov

o Sent to the Board directly from the other state IN AN ENVELOPE

SEALED BY THE STATE LICENSING AGENCY

o Enclosed with the application IN AN ENVELOPE SEALED BY THE

STATE LICENSING AGENCY.

• Submit an original Out-of-State Experience Verification form completed

by each supervisor. Use separate forms for each supervisor and each

employer. Other documentation of out-of-state experience such as W-2

forms are not required.

Note: The Board will accept all versions of the BBS Experience

Verification forms.

Verification(s) of

supervisor’s license

emailed or sent to the

Board in a SEALED

ENVELOPE OR

EMAILED AS

DIRECTED

Original Out-of-State

Experience

Verification form(s)

37A-319 (Revised 01/2022) 9

Path B – LICENSURE BY EDUCATION AND EXPERIENCE

3. SUPERVISED EXPERIENCE (continued)

Instructions for Applicants Who Must Submit Verification of Experience

Document(s) Required

Experience Gained WITHIN California:

EXPERIENCE VERIFICATION: Each supervisor must verify your

experience. Submit an In-State Experience Verification form, available on

the Board’s website. Must contain an original signature. Use separate

forms for each supervisor and each employer. Please note:

• The Board will accept all versions of the BBS Experience

Verification forms.

• Weekly Summary forms CANNOT be accepted in place of an

Experience Verification form. Do not submit Weekly Summary

forms unless requested.

W-2 FORMS: If you were employed while gaining post-degree hours, you

must submit a copy of your W-2 for each year you are claiming, and for

each employer. If your W-2 is not available, you must obtain a duplicate. If

a W-2 is not available for the current year, attach a copy of a current pay

stub. If your W-2 does not match the name of your employer listed on the

experience verification form, an explanation is required. If you are

submitting a 1099 form, an explanation is required.

VOLUNTEER LETTER: If you volunteered while gaining post-degree

hours, a letter from your employer is required indicating your voluntary

status on your employer’s letterhead. A sample letter is available on the

Board’s website. The letter must state the time frame (date range) during

which you volunteered and contain an original signature.

SUPERVISOR RESPONSIBILITY STATEMENT OR SUPERVISION

AGREEMENT: Submit a Supervisor Responsibility Statement or

Supervision Agreement for each supervisor. Must contain an original

signature.

LETTER OF AGREEMENT: Submit a copy of the written oversight

agreement for each supervisor and each employer, if applicable. See BPC

section 4980.43.4. Must contain original signatures.

Original In-State

Experience

Verification form(s)

Copies of W-2

Form(s)/Check stub

for current year (if

applicable)

Original Volunteer

Letter(s) (if applicable)

Original Supervisor

Responsibility

tatement(s) or

Supervision

Agreements

Original signed/dated

letter(s) of agreement

(if applicable)

37A-319 (Revised 01/2022) 10

Path B – LICENSURE BY EDUCATION AND EXPERIENCE

4. DEGREE REQUIREMENTS AND REMEDIATION

Instructions Document(s) Required

You must possess a master’s or doctoral degree obtained from a school

that holds a regional or national institutional accreditation recognized by

the U.S. Department of Education (USDE) or a school approved by the

California Bureau for Private Postsecondary Education (BPPE) (see # 5

for requirements if your degree was obtained outside the U.S.).

Provide official transcripts verifying your qualifying master’s or doctoral

degree with degree title and date of conferral posted as directed below:

• Mailed to the Board IN AN ENVELOPE SEALED BY THE

EDUCATIONAL INSTITUTION; or

• Sent electronically BY YOUR SCHOOL to the Board at

BBSLMFTtranscripts@dca.ca.gov (for questions about electronic

submission, see FAQ).

(Transcripts not required if currently registered as an Associate).

MARRIAGE, FAMILY AND CHILD COUNSELING / MARITAL AND

FAMILY SYSTEMS APPROACH:

Your degree must contain 12 semester units or 18 quarter units in this

area, or your degree will not qualify for licensure. Remediation is not

permitted.

OVERALL UNITS:

• Your degree must contain a minimum of 48 semester units or 72

quarter units or it will not qualify for licensure. Remediation is not

permitted.

• If you entered a degree program AFTER August 1, 2012: You are

required to complete a total 60 semester units or 90 quarter units. If

you are short units, up to 12 semester units or 18 quarter units can

be remediated outside of your degree program. Units must be

remediated before the Board can approve your Application for

Licensure and can be gained while registered as an Associate.

• Missing units must be taken at the graduate level from a school that

holds a regional or national institutional accreditation that is

recognized by the USDE, or a school approved by the BPPE.

Official transcript(s)

with degree title and

date of conferral

posted.

MUST BE SENT

ELECTRONICALLY OR

MAILED IN A SEALED

ENVELOPE AS

DIRECTED

(Not required if

currently registered as

an Associate)

Remediated Units (if

applicable):

Official transcript(s)

verifying remediated

units.

37A-319 (Revised 01/2022) 11

Path B – LICENSURE BY EDUCATION AND EXPERIENCE

4. DEGREE REQUIREMENTS AND REMEDIATION (continued)

Instructions Document(s) Required

PRACTICUM:

• Unlicensed applicants:

Your degree must contain at least 6 semester units or 9 quarter units

of supervised practicum which included at least 225 hours of face-to-

face experience counseling individuals, couples, families or groups

(the 225 hours may include up to 75 hours of client-centered

advocacy). Otherwise, your degree will not qualify for licensure.

Remediation is not permitted. There are no exceptions.

• Applicants licensed as an MFT at the highest level for independent

clinical practice in another state or country (and who hold a valid

license in good standing): The practicum requirement is waived.

See prior page

5. DEGREE EVALUATION

Instructions Document(s) Required

Disregard this section if you are currently registered with the BBS as an

Associate

OUT-OF-STATE DEGREE PROGRAM CERTIFICATION:

Provide an Out-of-State Degree Program Certification completed and

signed by your school’s Chief Academic Officer or authorized designee.

Must be in an envelope sealed by your school or sent by your school or

BBSLMFTtranscripts@dca.ca.gov. Not required if your degree was

obtained in another country.

DEGREE OBTAINED OUTSIDE THE U.S.:

If you have a degree or other education gained outside of the United

States, you must have your education evaluated by a foreign credential

evaluation service in order to determine equivalency. The service must be

a member of the National Association of Credential Evaluation Services.

Must be in an envelope sealed by the evaluating agency or sent by the

agency to the email address above.

The Board has the authority to make the final determination as to whether

a degree meets all requirements, including, but not limited to, course

requirements regardless of evaluation or accreditation. In addition to the

evaluation, an official sealed transcript is required.

Completed Out-of-

State Degree Program

Certification form.

MUST BE IN A

SEALED ENVELOPE

OR EMAILED AS

DIRECTED

Degree evaluation by

a foreign credential

evaluation service (if

applicable). MUST BE

IN A SEALED

ENVELOPE OR

EMAILED AS

DIRECTED

(Not required if

currently registered

as an Associate)

37A-319 (Revised 01/2022) 12

Path B – LICENSURE BY EDUCATION AND EXPERIENCE

6. CALIFORNIA LAW AND ETHICS COURSE

Instructions Document(s) Required

Disregard this section if you are currently registered with the BBS as an

Associate

You are required to complete a California Law and Ethics course as

described below:

• If your degree contains a 2 semester unit or 3 quarter unit course

on Law and Ethics: You must take a 12-hour California course.

See BPC section 4980.78(b)(2) for course content requirements.

The course may be taken from a school that holds a regional or

national institutional accreditation recognized by the USDE, a

school approved by the California BPPE, or an acceptable

continuing education provider.

• If your degree does NOT contain a 2 semester unit or 3 quarter unit

course on Law and Ethics: You must take a 2 semester unit or 3

quarter unit California course. See BPC section 4980.81(a)(8) for

course content requirements. The course may be taken from a

school that holds a regional or national institutional accreditation

recognized by the USDE, or a school approved by the California

BPPE.

Proof of completion of

California Law and

Ethics course

7. ADDIT

IONAL COURSEWORK

Instructions Document(s) Required

You must complete the California-specific coursework listed in Path B of

the Guide to LMFT Out-of-State Applicant Requirements.

If you submitted documentation of completion with a prior application, it is

not necessary for you to resubmit this information.

Proof of completion of

Additional Coursework

8. APPLY FOR INITIAL LICENSE ISSUANCE

Instructions Document(s) Required

Upon meeting all requirements for licensure, you must submit a Request

for Initial License Issuance and fee. Do not submit at this time – it will

be rejected.

AFTER you pass BOTH

exams, submit a Request

for Initial License

Issuance and fee

37A-317 (Revised 07/2020) 1

Important Information for

LICENSED MARRIAGE

AND FAMILY THERAPIST

APPLICANTS

1. ABANDONMENT OF LICENSURE APPLICATION

An application shall be deemed abandoned in any of the circumstances described below.

Abandonment could have major consequences, including the loss of any experience hours

more than six (6) years old at the time of application. Per Title 16, California Code of

Regulations Section 1806, an application shall be deemed abandoned when:

• You do not submit evidence that you have cleared the deficiencies specified in the

deficiency letter within one (1) year from the date of the initial deficiency letter.

• You fail to sit for examination within one (1) year after being notified of eligibility.

• You fail to pay the initial license fee within one (1) year after notification by the board of

successful completion of examination requirements.

To re-open an abandoned application, you must submit a new application, fee and all

required documentation, as well as meet all current licensure requirements in effect at the

time the new application is submitted.

2. EXAMINATION

Once the Board evaluates your application, you will receive one of the following:

• A notice describing any deficiencies in your application OR

• A notice of eligibility to take the examination.

o You will not be eligible to take the LMFT California Clinical Exam until you have

passed the LMFT California Law and Ethics Exam (or the former LMFT

Standard Written Exam). You will receive information on registering for each

exam upon approval of your application.

The examinations contain objective multiple-choice questions and are offered at locations

throughout California and in other states. Upon receipt of your notice of eligibility, it is your

responsibility to contact the testing administrator to schedule your examination. Further

information about the examination process is provided on the Board’s website.

37A-317 (Revised 07/2020) 2

3. REQUEST FOR TESTING ACCOMMODATION – DISABILITY OR ENGLISH AS A

SECOND LANGUAGE

Refer to the Board’s website for information on how to apply for testing accommodations.

4. NONDISCRIMINATION AND ADA COORDINATOR

The Executive Officer of the Board has been designated to coordinate and carry out the

Board’s compliance with the nondiscrimination requirements of Title II of the Americans

with Disabilities Act (ADA). Information concerning the provisions of the ADA, and the

rights provided hereunder, are available from the ADA coordinator.

5. PUBLIC ADDRESS and CHANGE OF ADDRESS

The address you enter on any Board form is public information and will be placed on the

Internet pursuant to Business and Professions Code section 27. If you do not want your

home or work address available to the public, use an alternate mailing address, such as a

post office box. California law requires all persons regulated by the Board to notify the

Board in writing within 30 days of any change of address.

6. STATUTES AND REGULATIONS

To obtain a copy of the Board’s Statutes and Regulations, please access it from the

Board’s website.

7. MANDATORY REPORTER

Under California law each person licensed by the Board of Behavioral Sciences is a

“mandated reporter” for both child, elder and/or dependent adult abuse or neglect

purposes. California Penal Code section 11166 and Welfare and Institutions Code section

15630 require that all mandated reporters make a report to an agency specified [generally

law enforcement, state, and/or county adult protective services agencies, etc… ] in Penal

Code section 11165.9 and Welfare and Institutions Code section 15630(b)(1) whenever

the mandated reporter, in their professional capacity or within the scope of their

employment, has knowledge of or observes a child, elder and/or dependent adult whom

the mandated reporter knows or reasonably suspects has been the victim of child abuse or

elder abuse or neglect.

The mandated reporter must make a report of such abuse or neglect immediately, or as

soon as practically possible, in the manner specified in Penal Code Section 11166 (for

child abuse or neglect) or in Welfare and Institutions Code Section 15630 (for elder or

dependent adult abuse or neglect). Failure to comply with the requirements of Penal Code

Section 11166 or Welfare and Institutions Code Section 15630 is a misdemeanor,

37A-317 (Revised 07/2020) 3

punishable by up to six months in a county jail, by a fine of one thousand dollars ($1,000),

or by both imprisonment and fine. For further details about these requirements, consult

Penal Code sections 11164 and Welfare and Institutions Code section 15630, and

subsequent sections.

8. SOCIAL SECURITY NUMBER OR OTHER TAXPAYER IDENTIFICATION NUMBER

Disclosure of your tax identification number on your application is mandatory. You may

provide either your Social Security Number, Federal Employer Identification Number, or

Individual Taxpayer Identification Number, as applicable. Section 30 of the Business and

Professions Code and Public Law 94-455 (42 USCA 405 (c) (2) (c)) authorizes collection

of these tax identification numbers. Your tax identification number will not be deemed a

public record and shall not be open to the public. Your tax identification number will be

used exclusively for tax enforcement purposes, for purposes of compliance with any

judgment or order for family support in accordance with section 17520 of the Family

Code, or for verification of licensure or examination status by a licensing or examination

entity which utilizes a national examination and where licensure is reciprocal with the

requesting state. If you fail to disclose your tax identification number, your application for

initial or renewal license will not be processed AND you will be reported to the Franchise

Tax Board, which may assess a $100 penalty against you.

9. STATE TAX OBLIGATION

Pursuant to Business and Professions Code section 31(e), the State Board of

Equalization and the Franchise Tax Board may share taxpayer information with the

Board. If a licensee or registrant does not pay their state tax obligation, the individual’s

license or registration may be suspended.

10. NOTICE OF COLLECTION OF PERSONAL INFORMATION:

The Board of Behavioral Sciences of the Department of Consumer Affairs collects the

personal information requested in the LMFT Application for Licensure as authorized by

Business and Professions Code sections 27, 30, 114.5, 480, 4980.36, 4980.37, 4980.40,

4980.41, 4980.43, 4980.44, 4980.72, 4980.74, 4980.78, 4980.79, 4980.81, 4982, 4982.25

and 4990.38; Title 16 of the California Code of Regulations sections 1805, 1806, 1833,

1833.1 and 1833.2; and the Information Practices Act. The Board uses this information

principally to identify and evaluate applicants for licensure, issue and renew licenses, and

enforce licensing standards set by statutes and regulations.

Mandatory Submission. Submission of the requested information is mandatory. The

Board cannot consider your application for registration, licensure or renewal unless you

provide all of the requested information (unless requested information is identified as

voluntary or optional).

37A-317 (Revised 07/2020) 4

Access to Personal Information. You may review the records maintained by the Board

of Behavioral Sciences that contain your personal information, as permitted by the

Information Practices Act. See below for contact information.

Possible Disclosure of Personal Information. We make every effort to protect the

personal information you provide us. The information you provide, however, may be

disclosed in the following circumstances:

• In response to a Public Records Act request (Government Code section 6250 and

following), as allowed by the Information Practices Act (Civil Code section 1798 and

following);

• To another government agency as required by state or federal law; or

• In response to a court or administrative order, a subpoena, or a search warrant.

Contact Information. For questions about this notice or access to your records, you may

contact the Board at (916) 574-7830 or by email at BBS.info@dca.ca.gov. For questions

about the Department of Consumer Affairs’ privacy policy or the Information Practices Act,

you may contact the Department of Consumer Affairs, 1625 North Market Blvd.,

Sacramento, CA 95834, (800) 952-5210 or email dca@dca.ca.gov.

37A-303 (Revised 01/2022) Page 1 of 3

APPLICATION FOR LICENSURE

LICENSED MARRIAGE

AND FAMILY THERAPIST

Out-of-State Applicant

GENERAL APPLICATION

To Be Completed by All Out-Of-State Applicants

Office Use Only:

Carefully read the Application Instructions FIRST

Attach Correct Fee

SSN or ITIN*

Birth Date: mm/dd/yyyy

E-Mail Address

Legal Name** Last

First

Middle

If you have ever been known by another name, list the full name(s) and dates of use below

(attach any additional names and dates):

Full Name

Dates of Use (from/to)

Full Name

Dates of Use (from/to)

Public Address of Record*** Number and Street

City

State

Zip Code

Phone

* Disclosure of your tax identification number is mandatory. You may provide either your Social Security

Number, your Federal Employer Identification Number, or Individual Taxpayer Identification Number, as

applicable. This number must match the number you provide on your fingerprint forms. See Important

Information for Applicants for more information about how your tax identification number is used.

** You must use your legal name. Your “legal name” is the name established legally by your birth

certificate, marriage or domestic partnership certificate, or divorce decree (for example).

*** The address you enter on this application is public information and will be placed on the Internet

pursuant to Business and Professions Code section 27. All correspondence from the Board will be

mailed to this address. If you do not want your home or work address available to the public, use an

alternate mailing address such as a post office box.

37A-303 (Revised 01/2022) Page 2 of 3

Applicant Name: Last

First

Middle

1. Have you ever served in the United States Armed Forces or the

California National Guard? (OPTIONAL)

Yes, Currently No

Yes, Previously

2. Have you ever applied for or been issued a license, registration or certificate

to practice marriage and family therapy or any other health care profession

in California or any other state?

If YES, provide the information requested below (continue on an additional

sheet if needed):

Yes No

State

Type of License, Registration

or Certificate

License, Registration

or Certificate Number

Date

Issued

Status

3. Within the 7 years preceding your submission of

this application, were you denied a professional

health care license (“license” includes

registrations, certificates, or other means to

engage in practice) OR had a professional

health care license or privilege suspended,

revoked, or otherwise disciplined, OR

voluntarily surrendered any such license in

California or any other state or territory of the

United States, or by any other governmental

agency or a foreign country?

Yes No

If YES, we recommend that you complete the

Background Statement form, available on the

Board’s website, to facilitate processing of your

application.

We recommend that you answer “Yes” even if

you have previously reported it to the Board, and

indicate the type of professional license that was

denied, suspended, disciplined, or surrendered,

including the date(s) of the denial, suspension,

disciplinary action, You do not need to resubmit

documentation previously on file.

4. If you hold or have held a license or registration to practice marriage and

family therapy outside of California, have you attached a Verification of

License or Registration form for each license or registration held?

Yes No

N/A

5. I am applying for: Licensure by Credential: I have attached the Application for Path A

Licensure by Education and Experience: I have attached the Application

for Path B

37A-303 (Revised 01/2022) Page 3 of 3

Applicant Name: Last

First

Middle

BACKGROUND INFORMATION – RESPONSE IS VOLUNTARY.

NOTE: Knowingly making a false statement of fact that is required to be revealed in this

application may be grounds for denial of this application.

Signature of Applicant: ______________________________________ Date: ____________

Some criminal convictions will appear on the Board's background check and may require additional

investigation prior to a licensing determination. For information on which convictions the Board is

permitted to consider, see the Criminal Conviction FAQ. All currently pending criminal actions will

appear on the Board’s background check and may require additional investigation prior to a licensing

determination.

You are not required to disclose any past convictions or pending criminal cases on this application. In

some cases, voluntarily providing information with the application about convictions that the Board is

permitted to consider may help an application get processed more quickly. You may therefore choose to

complete the Background Statement form and submit it with your application along with evidence of

rehabilitation. The form is available on the Board's website, and includes areas to report convictions the

board is permitted to consider, or pending criminal actions.

You can also submit the Background Statement form and evidence of rehabilitation after you submit your

application or in response to inquiries from the Board. You may seek legal assistance from a lawyer or

legal aid organization before providing any information about your criminal history. The Board will not

deny your application because you exercised your right not to provide criminal history information in your

initial application.

37A-303A (Revised 01/2021) Page 1 of 2

APPLICATION FOR LICENSURE

LICENSED MARRIAGE

AND FAMILY THERAPIST

Out-of-State Applicant

APPLICATION FOR PATH A.

LICENSURE BY CREDENTIAL

This form must be accompanied by a General Application

Applicant Name: Last

First

Middle

1. QUALIFICATIONS:

A. I have held a license as a Marriage and Family Therapist in another United

States jurisdiction for at least two years.

B. The license I hold is current, and has been active and unrestricted for at

least two years immediately before the date I submit my application to the

Board.

C. The license I hold is at the highest level for independent clinical practice in

that jurisdiction.

D. The degree that qualified me for this license is a master’s or doctoral degree

obtained from a school holding a regional or national institutional

accreditation recognized by the U.S. Department of Education, or a school

approved by the California Bureau for Private Postsecondary Education.

Yes No

If you answered NO to any of the above, you must instead apply using the Application for

Path B - Licensure by Education and Experience.

2. OFFICIAL TRANSCRIPTS:

Have you submitted official sealed transcripts verifying your

qualifying master’s or doctoral degree as described in 1.D.

above?

Yes – Sealed Transcripts via Mail

Yes – Electronic Transcripts

37A-303A (Revised 01/2021) Page 2 of 2

Applicant Name: Last

First

Middle

3. CALIFORNIA-SPECIFIC COURSEWORK:

List the course providers below and attach documentation of completion for each course. See

Application Instructions for course content and provider requirements.

a) Suicide Risk Assessment and Intervention (6 hours)

Provider Name:

b) California Law and Ethics (12 hours)

Provider Name:

c) Child Abuse Assessment and Reporting in California (7 hours)

Provider Name:

d) California Cultures and the Social and Psychological Implications of Socioeconomic Position

(15 hours)

Provider Name:

NOTE: Knowingly making a false statement of fact that is required to be revealed in this

application may be grounds for denial of this application.

Signature of Applicant: ______________________________________ Date:_____________

37A-661B (Revised 01/2022) Page 1 of 3

APPLICATION FOR LICENSURE

LICENSED MARRIAGE

AND FAMILY THERAPIST

Out-of-State Applicant

APPLICATION FOR PATH B.

LICENSURE BY EDUCATION AND EXPERIENCE

This form must be accompanied by a General Application

Applicant Name: Last

First

Middle

1. EXPERIENCE

Are you required to submit supervised experience hours?

(see Application Instructions to determine)

Yes No

If YES, have you attached the required verification of

experience?

Yes No

2. DEGREE REQUIREMENTS

a. Have you submitted official transcripts verifying your

qualifying master’s or doctoral degree?

See Application Instructions for transcript requirements.

Yes – Sealed Transcripts via Mail

Yes – Electronic Transcripts

b. Have you attached a sealed Degree Program Certification

form? See Application Instructions for requirements.

Yes No

Previously Submitted

3. DEGREE REMEDIATION

Were you required to remediate overall units for your degree

program as described in the Application Instructions?

Yes No

If YES, have you submitted official sealed transcripts

showing completion?

Yes No

4. CALIFORNIA LAW AND ETHICS COURSE (12 Hours)

Have you attached documentation of completion of the

required 12-hour course in California Law and Ethics as

described in the Application Instructions?

Yes No

Previously Submitted

37A-661B (Revised 01/2022) Page 2 of 3

Applicant Name: Last

First

Middle

5. ADDITIONAL COURSEWORK

List the titles of the courses you have completed and the course providers below. See the Guide to

LMFT Out-of-State Applicant Requirements for information on course content and provider

requirements. You must submit documentation of completion unless previously submitted.

a) Suicide Risk Assessment and Intervention (6 hours)

Course Title(s):

Provider(s):

b) Mental Health Recovery Oriented Care and Methods of Service Delivery (45 hours)

Course Title:

Provider:

Course Title:

Provider:

c) California Cultures, and the Social and Psychological Implications of Socioeconomic Position (15

hours)

Course Title(s):

Provider(s):

d) Diagnosis, Assessment, Prognosis and Treatment of Mental Disorders (2 semester units)

Course Title(s):

Provider(s):

e) Psychological Testing (15 hours or 1 semester unit)

Course Title(s):

Provider(s):

f) Psychopharmacology (15 hours or 1 semester unit)

Course Title(s):

Provider(s):

g) Developmental Issues from Infancy to Old Age (15 hours or 1 semester unit)

Course Title(s):

Provider(s):

37A-661B (Revised 01/2022) Page 3 of 3

Applicant Name: Last

First

Middle

5. ADDITIONAL COURSEWORK (continued)

h) Child Abuse Assessment and Reporting in California (7 hours)

Course Title(s):

Provider(s):

i) Aging, Long Term Care; Elder/Dependent Adult Abuse; End-of-Life and Grief (10 hours)

Course Title(s):

Provider(s):

j) Spousal or Partner Abuse Assessment, Detection and Intervention (15 hours)

Course Title(s):

Provider(s):

k) Multicultural Development and Cross-Cultural Interaction (15 hours or 1 semester unit)

Course Title(s):

Provider(s):

l) Human Sexuality (10 hours)

Course Title(s):

Provider(s):

m) Substance Use Disorders (15 hours)

Course Title(s):

Provider(s):

n) Co-Occurring Disorders and Addiction (15 hours)

Course Title(s):

Provider(s):

o) Miscellaneous Content (see Guide to LMFT Out-of-State Requirements page 8)

Course Title(s):

Provider(s):

NOTE: Knowingly making a false statement of fact that is required to be revealed in this

application may be grounds for denial of this application.

Signature of Applicant: ______________________________________ Date:_____________

37A-306 (Revised 01/2020)

STATE OF CALIFORNIA – BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY Gavin Newsom, Governor

ard of Behavioral Sciences

1625 North Market Blvd., Suite S200, Sacramento, CA 95834

(916) 574-7830

www.bbs.ca.gov

LICENSED MARRIAGE AND FAMILY THERAPIST

OUT-OF-STATE LICENSE OR REGISTRATION VERIFICATION

APPLICANT: Complete this section authorizing release of information by another state board or

licensing agency. Mail this form and any necessary fees to that licensing agency.

Verification For: Applicant Applicant’s Supervisor

Name of California Applicant:

Last

First

Middle

BBS File Number or IMF

Number

Name of Individual to be Verified:

Last

First

Middle

License Number

I hereby authorize the release of my information to the California Board of Behavioral Sciences.

Signature of individual to be verified: _________________________________ Date:_________

STATE BOARD/LICENSING AGENCY: Please return this form to the above address.

1. Full name as shown in your records: ________________________________________________

2. License or Registration Title: _____________________________________________________

3. License or Registration Status: ____________________________________________________

Issue Date: _____________ Expiration Date: _____________

4. Any disciplinary action? No Yes (If YES, attach an explanation)

State Board/Licensing Agency

Stamp Here

Signature of Person Completing Form Date

Printed Name and Title

State Board or Licensing Agency Name

State Phone Number

37A-304 (Revised 01/2022) 1 of 2

STATE OF CALIFORNIA – BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY Gavin Newsom, Governor

Board of Behavioral Sciences

1625 North Market Blvd., Suite S200, Sacramento, CA 95834

(916) 574-7830

www.bbs.ca.gov

LICENSED MARRIAGE AND FAMILY THERAPIST

OUT-OF-STATE EXPERIENCE VERIFICATION

This form is for unlicensed applicants. It must be completed by the applicant’s out-of-state supervisor

and submitted by the applicant with their Application for Licensure. All information on this form is

subject to verification. Be sure to:

• Use separate forms for pre-degree and post-degree experience.

• Use separate forms for each supervisor and each employment setting.

• Ensure that the form is complete and correct prior to signing.

• Have the supervisor initial any changes.

APPLICANT NAME:

Last

First

Middle

Associate Number

AMF

SUPERVISOR INFORMATION:

Supervisor’s Name

Telephone

Email Address

License Type

License Number

State

Date First Licensed

• Physicians: Were you certified in Psychiatry by the American Board of Psychiatry and Neurology

during the entire period of supervision?

No Yes: Date Board Certified: ___________ Certification Number: _________________

The hours

reported on this

form were earned

as (mark one):

 Pre-Degree

 Post-Degree

37A-304 (Revised 01/2022) 2 of 2

Applicant: Last

First

Middle

APPLICANT’S EMPLOYER INFORMATION:

Name of Applicant’s Employer

Telephone

Address Number and Street

City

State

Zip Code

EXPERIENCE INFORMATION:

1. Dates of experience being claimed:

From: __________________

mm/dd/yyyy

To: _____________________

mm/dd/yyyy

2. How many weeks of supervised experience are being claimed? __________ Weeks

3. Hours of Experience: Total Hours

a. Total Direct Counseling Experience (Minimum 1,750 hours)

• Of the above hours, how many were gained diagnosing and treating

Couples, Families and Children? (Minimum 500 of the 1,750 hours)

b. Total Non-Clinical Experience (Maximum 1,250 hours)

• Of the above hours, how many were Face-to-Face

Supervision?

Hours Per Week

Total Hours

Individual or Triadic

Group

NOTE: Knowingly providing false information or omitting pertinent information may be

grounds for denial of the application. The Board may take disciplinary action on a licensee

who helps an applicant obtain a license by fraud, deceit or misrepresentation. All information

on this form is subject to verification.

Signature of Supervisor: _______________________________________ Date: _____________

ORIGINAL OR ELECTRONIC SIGNATURE REQUIRED

)!(

BBS

□ □

__________________________________________________________________

STATE OF CALIFORNIA – BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY Gavin Newsom, Governor

Board of Behavioral Sciences

1625 North Market Blvd., Suite S200, Sacramento, CA 95834

(916) 574-7830

www.bbs.ca.gov

MARRIAGE AND FAMILY THERAPIST

DEGREE PROGRAM CERTIFICATION

OUT-OF-STATE DEGREE

This form is for use by all applicants with an Out-of-State Degree

Type or print clearly in ink

Applicant Name: Last

First

Middle

SSN or Individual Taxpayer ID Number:

Enrollment Date:

Degree Award Date:

APPLICANT: The purpose of this form is for your school to verify the specifics of a degree program

completed outside of California. Enclose it

with your application in an envelope that has been sealed

by your school or sent by your school via email. The Board may require additional information to

verify course content.

SCHOOL: The applicant named above is applying for licensure in California. Please complete this

form, including the certification, and provide the applicant with the original IN A SEALED ENVELOPE

or sent to BBSLMFTtranscripts@dca.ca.gov. The full legal text of the educational requirements is

located in the California Business and Professions Code (BPC), available on the Board’s website

under Statutes and Regulations.

1. Number of units in degree: __________ Semester units Quarter Units

2. Yes No The degree program contained no less than six (6) semester or nine (9) quarter

units of supervised practicum, and 225 hours of experience that included the

following:

• At least 150 hours providing face-to-face counseling to individuals, couples,

families or groups AND

• At least 75 additional hours providing either face-to-face counseling and/or

client-centered advocacy

Number of units: _____ Number of counseling experience hours: _____

Number of client-centered advocacy hours: _____

Course number(s)/Term(s): ___________________________________________

37A-599 (Revised 01/2022) 1 of 2

□ □

□

_______________________________________________________________

Applicant Name: Last

First

Middle

3. Yes No The degree program included no less than 12 semester or 18 quarter units of

coursework in the areas of marriage, family, and child counseling and marital and

family systems approaches to treatment, including all of the following:

• Theories, principles, and methods of a variety of psychotherapeutic

orientations directly related to marriage and family therapy, and marital and

family systems approaches to treatment.

• How these theories can be applied therapeutically with couples, families,

adults, elder adults, children, adolescents and groups to improve, restore, or

maintain healthy relationships.

Number of units: ____ Course number(s)/Term(s): _____________________

4. Yes No

5. Yes No

The applicant has completed coursework in the diagnosis, assessment, prognosis,

treatment planning, and treatment of mental disorders including severe mental

disorders, evidence-based practices, and promising mental health practices that are

evaluated in peer reviewed literature.

Number of units: ____ Course number(s)/Term(s): ________________________

________________________________________________________________________________

Did the applicant’s degree program contain 6 hours of content related to suicide risk

assessment and intervention? (Note: Not required to be part of degree program)

CERTIFICATION

I hereby certify that all of the foregoing is true and correct

Signature of Chief Academic Officer or

Name of Institution

Authorized Designee

Print Name

Institution Accredited or Approved by

Date Signed

37A-599 (Revised 01/2022) 2 of 2

37A-648 (Revised 06/2020) 1

STATE OF CALIFORNIA - BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY Gavin Newsom, Governor

Board of Behavioral Sciences

1625 North Market Blvd., Suite S200, Sacramento, CA 95834

Telephone: (916) 574-7830

www.bbs.ca.gov

INSTRUCTIONS FOR LIVE SCAN FINGERPRINTING

AND PRIVACY NOTICES

Live Scan Fingerprinting is available only in California. Live Scan fingerprint results will be

submitted to the Department of Justice (DOJ) and the Federal Bureau of Investigation

(FBI) electronically.

If you need to have your fingerprints taken in another state, you must use the "hard card"

fingerprint method. To request hard cards and instructions, send an email to

BBS.Fingerprint@dca.ca.gov with "Fingerprint Hard Cards" in the subject line, and include

your mailing address. Please be advised that the DOJ processing time for hard card

fingerprints is a minimum of 8 to 12 weeks, or longer. In order to avoid processing delays

and additional costs that result from invalid fingerprint cards, fingerprints must be taken at a

law enforcement agency in the state of residence.

Fingerprint Fees - Paid to Live Scan Site

If you have your prints taken via Live Scan, you must pay the fingerprint fees below

directly to the site where you have your Live Scan fingerprints taken:

DOJ FINGERPRINT PROCESSING FEE: $32.00

FBI FINGERPRINT PROCESSING FEE: $17.00

In addition to these processing fees, there may be a service charge associated with

the Live Scan site you visit. The Live Scan service site will collect the above fees at the

time you are fingerprinted. The Live Scan service charge may vary from location to

location.

Complete the Request for Live Scan Service Form

You must complete and submit the attached Request for Live Scan Service form at the

Live Scan site. Make sure that the information provided in Section 3 of the form matches

the information on your BBS application. Once your fingerprints have been scanned, the

Live Scan Operator will complete Section 4 of this form and return the second and third

copies to you.

The second copy of this form, with Section 4 completed by the Live Scan Operator,

must be MAILED to the BBS in order to retrieve your fingerprint results from the DOJ.

Retain the third copy for your records as a proof of payment.

37A-648 (Revised 06/2020) 2

Live Scan Fingerprint Locations

You must visit an approved Live Scan Service Site. Most local Police and Sheriff

Departments offer the Live Scan fingerprinting service. Some large school districts,

passport services, and stores with generalized fingerprinting expertise may also offer Live

Scan. A current listing of Live Scan sites is available on the DOJ website at

https://oag.ca.gov/fingerprints/locations.

Consider calling the Live Scan service provider for hours of operation, fees, and

appointment times if necessary. You must present valid photo identification (i.e., driver’s

license, military ID, or passport) at the Live Scan site.

Filling Out Your Live Scan Form

To facilitate prompt and accurate processing, please TYPE or print legibly in ink.

SECTION 1: Type of Application: LIC/CERT/PERMIT

Check the box for the applicable registration or license you are applying for with the BBS.

Even if you are applying for more than one registration or license type, CHECK THE BOX

FOR ONLY ONE LICENSE TYPE. Your fingerprint results will be put towards ALL

registrations and licenses you hold. You do not need to pay or be fingerprinted for each

individual BBS license type.

SECTION 2: This section is already completed.

SECTION 3:

Name of Applicant: Enter your full name

Alias: Indicate all other names used

Date of Birth: Indicate your month/day/year of birth

Sex: Mark the appropriate box

Height: Indicate your height in feet and inches

Weight: Indicate your weight in pounds (lbs.)

Eye Color: Indicate eye color abbreviation:

BLK - Black

GRY - Gray

MAR - Maroon

BLU - Blue

GRN - Green

PNK – Pink

BRO - Brown

HAZ - Hazel

MUL - Multicolor

Hair Color: Indicate hair color abbreviation:

BAL - Bald

BRO - Brown

SDY - Sandy

BLK - Black

GRY - Gray

WHI - White

BLN - Blonde

RED - Red

37A-648 (Revised 06/2020) 3

Place of Birth:

Social Security

Number:

Driver’s License

No:

Indicate the state or country of birth

Enter your SSN or individual taxpayer ID number. Must match the

number provided on your application.

Enter your Driver’s license number if you have one.

Address: Enter a mailing address of your choice. You may use a business

address, your home address, or any current address. This

address will not be viewable by the public, and will be used

solely for the BBS’ records.

Your BBS File number:

Enter your BBS file number. If you are a brand new applicant and do not currently hold an

identifying number, leave this line blank.

If Resubmission, List Original ATI No.

This is only used for a second fingerprinting due to a prior fingerprint rejection. The ATI No.

allows you to be re-fingerprinted without paying the DOJ and FBI processing fee (service

charges may still apply.)

Applicant Signature

Sign and date the application to indicate that you have read the included Privacy Notice,

Privacy Act Statement and Applicant’s Privacy Rights.

SECTION 4:

To be completed by the Live Scan operator.

REQUEST FOR LIVE SCAN SERVICE

Privacy Notice

As Required by Civil Code § 1798.17

Collection and Use of Personal Information. The California Justice Information Services

(CJIS) Division in the Department of Justice (DOJ) collects the information requested on this

form as authorized by Business and Professions Code sections 4600-4621, 7574-7574.16,

26050-26059, 11340-11346, and 22440-22449; Penal Code sections 11100-11112, and

11077.1; Health and Safety Code sections 1522, 1416.20-1416.50, 1569.10-1569.24, 1596.80-

1596.879, 1725-1742, and 18050-18055; Family Code sections 8700-87200, 8800-8823, and

8900-8925; Financial Code sections 1300-1301, 22100-22112, 17200-17215, and 28122-

28124; Education Code sections 44330-44355; Welfare and Institutions Code sections 9710-

9719.5, 14043-14045, 4684-4689.8, and 16500-16523.1; and other various state statutes and

regulations. The CJIS Division uses this information to process requests of authorized entities

that want to obtain information as to the existence and content of a record of state or federal

convictions to help determine suitability for employment, or volunteer work with children, elderly,

or disabled; or for adoption or purposes of a license, certification, or permit. In addition, any

personal information collected by state agencies is subject to the limitations in the Information

Practices Act and state policy. The DOJ's general privacy policy is available at

http://oag.ca.gov/privacy-policy.

Providing Personal Information. All the personal information requested in the form must be

provided. Failure to provide all the necessary information will result in delays and/or the

rejection of your request.

Access to Your Information. You may review the records maintained by the CJIS Division in

the DOJ that contain your personal information, as permitted by the Information Practices Act.

See below for contact information.

Possible Disclosure of Personal Information. In order to process applications pertaining to

Live Scan service to help determine the suitability of a person applying for a license,

employment, or a volunteer position working with children, the elderly, or the disabled, we may

need to share the information you give us with authorized applicant agencies. The information

you provide may also be disclosed in the following circumstances:

• With other persons or agencies where necessary to perform their legal duties, and their

use of your information is compatible and complies with state law, such as for

investigations or for licensing, certification, or regulatory purposes.

• To another government agency as required by state or federal law.

Contact Information. For questions about this notice or access to your records, you may

contact the Associate Governmental Program Analyst at the DOJ's Keeper of Records at (916)

210-3310, by email at keeperofrecords@doj.ca.gov, or by mail at: Department of Justice Bureau

of Criminal Information & Analysis Keeper of Records P.O. Box 903417 Sacramento, CA

94203-4170.

REQUEST FOR LIVE SCAN SERVICE

Privacy Act Statement

Authority. The FBI's acquisition, preservation, and exchange of fingerprints and associated

information is generally authorized under 28 U.S.C. 534. Depending on the nature of your

application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L.

92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and

associated information is voluntary; however, failure to do so may affect completion or approval

of your application.

Principal Purpose. Certain determinations, such as employment, licensing, and security

clearances, may be predicated on fingerprint-based background checks. Your fingerprints and

associated information/biometrics may be provided to the employing, investigating, or otherwise

responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other

fingerprints in the FBI's Next Generation Identification (NGI) system or its successor systems

(including civil, criminal, and latent fingerprint repositories) or other available records of the

employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints

and associated information/biometrics in NGI after the completion of this application and, while

retained, your fingerprints may continue to be compared against other fingerprints submitted to

or retained by NGI.

Routine Uses. During the processing of this application and for as long thereafter as your

fingerprints and associated information/biometrics are retained in NGI, your information may be

disclosed pursuant to your consent, and may be disclosed without your consent as permitted by

the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the

Federal Register, including the Routine Uses for the NGI system and the FBI's Blanket Routine

Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental, or

authorized non-governmental agencies responsible for employment, contracting, licensing,

security clearances, and other suitability determinations; local, state, tribal, or federal law

enforcement agencies; criminal justice agencies; and agencies responsible for national security

or public safety.

REQUEST FOR LIVE SCAN SERVICE

Noncriminal Justice Applicant's Privacy Rights

As an applicant who is the subject of a national fingerprint-based criminal history record check for a

noncriminal justice purpose (such as an application for employment or a license, an immigration or

naturalization matter, security clearance, or adoption), you have certain rights which are discussed

below.

• You must be provided written notification

that your fingerprints will be used to check the

criminal history records of the FBI.

• You must be provided, and acknowledge receipt of, an adequate Privacy Act Statement

when you submit your fingerprints and associated personal information. This Privacy Act

Statement should explain the authority for collecting your information and how your

information will be used, retained, and shared.

• If you have a criminal history record, the officials making a determination of your suitability for

the employment, license, or other benefit must provide you the opportunity to complete or

challenge the accuracy of the information in the record

• The officials must advise you that the procedures for obtaining a change, correction, or

update of your criminal history record are set forth at Title 28, Code of Federal Regulations

(CFR), Section 16.34.

• If you have a criminal history record, you should be afforded a reasonable amount of time to

correct or complete the record (or decline to do so) before the officials deny you the

employment, license, or other benefit based on information in the criminal history record

You have the right to expect that officials receiving the results of the criminal history record check

will use it only for authorized purposes and will not retain or disseminate it in violation of federal

statute, regulation or executive order, or rule, procedure or standard established by the National

Crime Prevention and Privacy Compact Council.

If agency policy permits, the officials may provide you with a copy of your FBI criminal history record

for review and possible challenge. If agency policy does not permit it to provide you a copy of the

record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI.

Information regarding this process may be obtained at

https://www.fbi.gov/services/cjis/identity-

history-summary-checks

If you decide to challenge the accuracy or completeness of your FBI criminal history record, you

should send your challenge to the agency that contributed the questioned information to the FBI.

Alternatively, you may send your challenge directly to the FBI. The FBI will then forward your

challenge to the agency that contributed the questioned information and request the agency to verify

or correct the challenged entry. Upon receipt of an official communication from that agency, the FBI

will make any necessary changes/corrections to your record in accordance with the information

supplied by that agency. (See 28 CFR 16.30 through 16.34.) You can find additional information on

the FBI website at https://www.fbi.gov/about-us/cjis/background-checks

1 Written notification includes electronic notification, but excludes oral notification

2 https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement

3 See 28 CFR 50.12(b) 4 See U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. §

14616), Article IV(c)

4 See U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616), Article IV(c)

State of California

REQUEST FOR LIVE SCAN SERVICE

BCII 8016 (04/2020)

Applicant Submission

APPLICANT

SECTION 1

ORI: A0462

(Code assigned by DOJ)

Type of License: (Mark Only ONE)



Marriage and Family Therapist



Educational Psychologist

Type of Application: LIC/PERMIT/CERT



Clinical Social Worker



Professional Clinical Counselor

SECTION 2

Agency Authorized to Receive Criminal Record

Information:

Board of Behavioral Sciences

1625 North Market Blvd. Suite S-200

Sacramento CA 95834

Mail Code: 01484

Contact Name: Fingerprint Unit

Contact Phone: (916) 574-7859

SECTION 3

Name of Applicant: ______________________________

(Please Print) Last

Alias: _________________________________________

Last First

Date of Birth: ____________ Sex:  Male  Female

Height: ________________ Weight: _______________

Eye Color: _____________ Hair Color: ____________

Place of Birth: __________________________________

Social Security Number: __________________________

_____________________________ ______

First MI

Driver’s License No.: ____________________

Billing No.: APPLICANT MUST PAY

Address:

______________________________________

Number and Street

________________________ ____ ________

City State Zip

BBS File Number: __________________________

If Resubmission, list Original ATI No.:

_________________________________________

(Must provide proof of rejection)

BBS Applicant: Please mail a copy of this

form to the address in Section 2 with your

BBS application.

Level of Service:  DOJ  FBI

I have received and read the included Privacy Notice, Privacy Act Statement and Applicant’s Privacy Rights.

Applicant Signature: _____________________________________ Date: __________

SECTION 4

Live Scan Transaction Completed By: ____________________________________ Date: _____________

Transmitting Agency: ___________________________________________ LSID: __________________

ATI No.: _________________________ Amount Collected/Billed: _______________________________

ORIGINAL – Live Scan Operator SECOND COPY – Requesting Agency THIRD COPY - Applicant

37A-649 (Revised 06/2020)

State of California

REQUEST FOR LIVE SCAN SERVICE

BCII 8016 (04/2020)

Applicant Submission

APPLICANT

SECTION 1

ORI: A0462

(Code assigned by DOJ)

Type of License: (Mark Only ONE)



Marriage and Family Therapist



Educational Psychologist

Type of Application: LIC/PERMIT/CERT



Clinical Social Worker



Professional Clinical Counselor

SECTION 2

Agency Authorized to Receive Criminal Record

Information:

Board of Behavioral Sciences

1625 North Market Blvd. Suite S-200

Sacramento CA 95834

Mail Code: 01484

Contact Name: Fingerprint Unit

Contact Phone: (916) 574-7859

SECTION 3

Name of Applicant: ______________________________

(Please Print) Last

Alias: _________________________________________

Last First

Date of Birth: ____________ Sex:  Male  Female

Height: ________________ Weight: _______________

Eye Color: _____________ Hair Color: ____________

Place of Birth: __________________________________

Social Security Number: __________________________

_____________________________ ______

First MI

Driver’s License No.: ____________________

Billing No.: APPLICANT MUST PAY

Address:

______________________________________

Number and Street

________________________ ____ ________

City State Zip

BBS File Number: __________________________

If Resubmission, list Original ATI No.:

_________________________________________

(Must provide proof of rejection)

BBS Applicant: Please mail a copy of this

form to the address in Section 2 with your

BBS application.

Level of Service:  DOJ  FBI

I have received and read the included Privacy Notice, Privacy Act Statement and Applicant’s Privacy Rights.

Applicant Signature: _____________________________________ Date: __________

SECTION 4

Live Scan Transaction Completed By: ____________________________________ Date: _____________

Transmitting Agency: ___________________________________________ LSID: __________________

ATI No.: _________________________ Amount Collected/Billed: _______________________________

ORIGINAL – Live Scan Operator SECOND COPY – Requesting Agency THIRD COPY - Applicant

37A-649 (Revised 06/2020)

State of California

REQUEST FOR LIVE SCAN SERVICE

BCII 8016 (04/2020)

Applicant Submission

APPLICANT

SECTION 1

ORI: A0462

(Code assigned by DOJ)

Type of License: (Mark Only ONE)



Marriage and Family Therapist



Educational Psychologist

Type of Application: LIC/PERMIT/CERT



Clinical Social Worker



Professional Clinical Counselor

SECTION 2

Agency Authorized to Receive Criminal Record

Information:

Board of Behavioral Sciences

1625 North Market Blvd. Suite S-200

Sacramento CA 95834

Mail Code: 01484

Contact Name: Fingerprint Unit

Contact Phone: (916) 574-7859

SECTION 3

Name of Applicant: ______________________________

(Please Print) Last

Alias: _________________________________________

Last First

Date of Birth: ____________ Sex:  Male  Female

Height: ________________ Weight: _______________

Eye Color: _____________ Hair Color: ____________

Place of Birth: __________________________________

Social Security Number: __________________________

_____________________________ ______

First MI

Driver’s License No.: ____________________

Billing No.: APPLICANT MUST PAY

Address:

______________________________________

Number and Street

________________________ ____ ________

City State Zip

BBS File Number: __________________________

If Resubmission, list Original ATI No.:

_________________________________________

(Must provide proof of rejection)

BBS Applicant: Please mail a copy of this

form to the address in Section 2 with your

BBS application.

Level of Service:  DOJ  FBI

I have received and read the included Privacy Notice, Privacy Act Statement and Applicant’s Privacy Rights.

Applicant Signature: _____________________________________ Date: __________

SECTION 4

Live Scan Transaction Completed By: ____________________________________ Date: _____________

Transmitting Agency: ___________________________________________ LSID: __________________

ATI No.: _________________________ Amount Collected/Billed: _______________________________

ORIGINAL – Live Scan Operator SECOND COPY – Requesting Agency THIRD COPY - Applicant

37A-649 (Revised 06/2020)

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APPLICATION FOR LICENSURE OUT-OF-STATE LICENSED MARRIAGE AND FAMILY (California)

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