Fill - Free fillable Documentation of Experience for General Counseling Experience Only (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) PDF form

PROOF

New Jersey Ofce of the Attorney General

Division of Consumer Affairs

State Board of Marriage and Family Therapy Examiners

124 Halsey Street, 6th Floor, P.O. Box 45007

Newark, New Jersey 07101

(973) 504-6415

Documentation of Experience

for General Counseling Experience Only

Name of Applicant _______________________________________________

(The requirement for general counseling experience is a minimum of one year which means at least

1,500

hours).

Directionss: This form is to be lled out by the applicant and veried by the supervisor or director of counseling/therapy in the

institution, organization, or other setting of the stated experience. A separate form must be used for each counseling setting.

These are hours that are not broken out into client contact, supervision, etc.

EXPERIENCE PRIOR TO DATE OF INITIAL APPLICATION

EXPERIENCE AFTER DATE OF INITIAL APPLICATION

____________________________________________________________________________________________________________

EXPERIENCE PRIOR TO RECEIVING QUALIFYING DEGREE\CERTIFICATE

EXPERIENCE AFTER RECEIVING QUALIFYING DEGREE/CERTIFICATE

1. Name and location of institution, organization or other setting

________________________________________________________________________________________________________

2. Inclusive dates, weeks, days, and hours:

(a) From (month/day/year)__________ To (month/day/year)_________

(b) Number of weeks _____________

(c) Number of days per week ____________

(d) Number of counseling hours per day ________ ______ Total Hours

3. Description of Applicant's Position and Responsibilities

Title: _______________________________________________________

Type of Counseling: _______________________________________________________________________________________

_______________________________________________________________________________________________________

Responsibilities:

________________________________________________________________________________________________________

Signature of applicant: __________________________________________________ Date: _______________________________

Signature of Supervisor/Director: __________________________________________ Date __________________________

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