Fillable Lmft Clinical Exam App LMFT CLINICAL EXAM APPLICATION

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Lmft Clinical Exam App LMFT CLINICAL EXAM APPLICATION

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See Application Instructions for Important Information
$100 FEE MUST ACCOMPANY THIS FORM
Allow 4–6 weeks for processing
(Type or print clearly in ink)
1.SSN or ITIN*
2. E-mail Address (OPTIONAL):
4. Legal Name: Last
First Middle
5. Address of Record: Number and Street
City
State Zip Code
6. Is this a new address?
Yes No
If YES, we will update our records accordingly
7.Business Phone: 8. Residence Phone:
APPLICATION FOR
INITIAL LMFT CALIFORNIA
CLINICAL EXAMINATION
NOTE: Knowingly providing false information or omitting pertinent information may be grounds for denial of this application.
Signature of Applicant Date
*
You may provide either your Social Security Number or Individual Taxpayer Identification Number, as applicable. Disclosure of your SSN or
ITIN is mandatory. Section 30 of the Business and Professions Code and Public Law 94-455 (42 USCA 405(c)(2)(C)) authorizes collection of
your SSN or ITIN, which will be used exclusively for tax enforcement purposes, for purposes of compliance with any judgment or order
for family support in accordance with Section 11350.6 of the Welfare and Institutions Code, or for verification of licensure or examination
status by a licensing or examination entity that utilizes a national examination and where licensure is reciprocal with the requesting state. If
you fail to disclose your SSN or ITIN you will be reported to the Franchise Tax Board, which may assess a $100 penalty against you.
STATE OF CALIFORNIA — BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY — DEPARTMENT OF CONSUMER AFFAIRS
BOARD OF BEHAVIORAL SCIENCES
1625 North Market Blvd., Suite S200, Sacramento, CA 95834
Phone: (916) 57
4-7830 TTY: (800) 326-2297 FAX: (916) 574-8625 www.bbs.ca.gov
37A-299 (Revised 01/2020)
Office Use Only:
Instructions and Important Information
APPLICATION FOR
INITIAL LMFT CALIFORNIA
CLINICAL EXAMINATION
FEE
A $100 fee must accompany your
Application for Initial LMFT California Clinical Examination
. Make your
check payable to “Behavioral Sciences Fund.”
WHO CAN APPLY
The application and fee will ONLY be accepted from individuals who have passed the LMFT California Law and
Ethics Examination and whose hours of experience and education have been approved by the Board.
TO CONFIRM YOUR APPLICATION WAS RECEIVED
To confirm receipt, mail your application using a method that includes tracking.
HOW LONG WILL IT TAKE FOR THE BOARD TO PROCESS MY APPLICATION?
Allow 4–6 weeks for processing. Please do not contact the Board to check on the status unless your application
has been on file for 45 or more days.
Pearson Vue administers the LMFT California Clinical Examination. After the Board processes your
Application
for Initial LMFT California Clinical Examination
, you will receive an e-mail notifying you of your eligibility from
Pearson Vue. You may contact Pearson Vue to schedule your examination once you receive the e-mail. Do not
attempt to schedule an examination date with Pearson Vue until you receive notification of eligibility.
Pearson Vue testing centers are located throughout the state as well as some out of state, offering testing 5–6
days a week. Refer to the Candidate Handbook for exact locations of testing sites.
CHANGE OF ADDRESS
If your mailing address has changed, be sure to update it on the BreEZe system online.
YOUR E-MAIL ADDRESS MUST BE ON FILE
Your email address must be on file in order to allow the Board’s testing vendor, Pearson Vue, to provide you
with notification of eligibility to schedule your examination. If you have not yet notified the Board of your email
address, be sure to add it on the BreEZe system online.
EXPEDITED PROCESSING – MILITARY SPOUSE/PARTNER AND HONORABLY DISCHARGED
VETERANS ONLY
The Board is required to expedite the licensure process for (1) an applicant who is a honorably discharged
veteran of the U.S. armed forces or (2) an applicant whose spouse or partner is an active-duty member of the
U.S. armed forces and meets other criteria pursuant to BPC Section 115.5. Download the application available
on the Board’s website and include it ON TOP OF your
Application for Initial LMFT California Clinical
Examination
.
continued on Page 2
Instructions and Important Information — Page 2
TESTING ACCOMMODATIONS
Reasonable accommodations will be provided to candidates who have a qualifying disability or medical
condition. All testing sites are physically accessible to individuals with disabilities. All other accommodations
require pre-approval.
Request for Accommodation
instructions are available on the Board’s website. If English
is your second language (ESL), you may apply for an ESL accommodation.
ABANDONMENT OF APPLICATION
In accordance with Title 16, California Code of Regulations Section 1806, your file will be deemed abandoned if:
You fail to sit for the examination within one year after being notified of eligibility to take the examination.
You fail to sit for the clinical examination within one year of being notified of passing the law and ethics
examination.
You fail to retake an examination within one year from the date you were notified of failing the examination.
To reopen an abandoned file you must submit a new application, fee, and all required documentation, as
well as meet all current requirements in effect at the time the new application is submitted.
STATE OF CALIFORNIA — BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY — DEPARTMENT OF CONSUMER AFFAIRS
BOARD OF BEHAVIORAL SCIENCES
1
625 North Market Blvd., Suite S200, Sacramento, CA 95834
Phone: (916) 574-7830 TTY: (800) 326-2297 FAX: (916) 574-8625 www.bbs.ca.gov
37A-299 IN (Revised 01/2020)
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Lmft Clinical Exam App LMFT CLINICAL EXAM APPLICATION

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Completed 14 May 2020

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