Fillable Initial Lic Iss APPLICATION FOR INITIAL LICENSE ISSUANCE

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Initial Lic Iss APPLICATION FOR INITIAL LICENSE ISSUANCE

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37M-308 (Revised 01/2020)
APPLICATION FOR
INITIAL LICENSE ISSUANCE
Instructions and Important Information
Read Carefully Before Completing Your Application
ELIGIBILITY FOR INITIAL LICENSE ISSUANCE AND TIME LIMIT
You must have passed the required examination(s) before your Application for Initial License
Issuance can be accepted by the Board. You must apply and submit the initial license fee within
one year after you are notified that you have successfully completed the examination
requirements. Otherwise your application will be considered abandoned and you will need to
submit a new Application for Licensure and fee.
HOW TO APPLY
• Complete the attached application.
• FEE: Attach a check or money order in the amount shown below payable to
“Behavioral Sciences Fund”:
License Type Initial License Fee License Type Initial License Fee
LMFT
$130
LPCC
$200
LCSW
$100
LEP
$80
• Submit your application and fee to the address below:
Board of Behavioral Sciences
1625 North Market Blvd., Suite S200
Sacramento CA 95834
TO CONFIRM RECEIPT OF APPLICATION:
To confirm receipt, mail your application using a method that includes tracking. You may also
contact your bank to see if your check has been cashed.
ADDRESS CHANGE:
If your address has changed, be sure to update it ASAP online at www.breeze.ca.gov.
APPLICATION PROCESSING TIME
Allow 30 working days for processing. Once your request has been approved your license will first
appear online at www.breeze.ca.gov, and then you will receive a license certificate in the mail.
QUESTIONS?
Please visit the Contact Us link at www.bbs.ca.gov and select an option under “Message the
Board.”
37M-308 (Revised 01/2020)
APPLICATION FOR
INITIAL LICENSE ISSUANCE
Office Use Only:
Carefully read the “Instructions and Important Information” FIRST
Attach Correct Fee Allow 30 Working Days for Processing
License Type Fee License Type Fee License Type Fee License Type Fee
LMFT
$130
LPCC
$200
LCSW
LEP
$80
License Type: LMFT LPCC LCSW LEP
SSN or ITIN*:
Birth Date mm/dd/yyyy:
Legal Name**: Last First Middle
* You may provide either your Social Security Number, your Federal Employer Identification
Number, or Individual Taxpayer Identification Number, as applicable.
** 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).
If you have a name change that you would like processed with your application, you must
attach the “Notification of Name Change” form and all required documentation. This form is
available online at https://www.bbs.ca.gov/pdf/forms/change_name.pdf. Your license will
reflect your new name only if a complete “Notification of Name Change” is received with your
application. Do not send original documents unless specifically requested.
NOTE: Knowingly providing false information or omitting pertinent information may be
grounds for denial of this application. The Board may refuse to issue a license, or may
suspend or revoke the license if the applicant secures the license by fraud, deceit, or
misrepresentation.
Signature of Applicant Date
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Initial Lic Iss APPLICATION FOR INITIAL LICENSE ISSUANCE

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Completed 14 May 2020

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