Fillable Mftapp Application for Marriage and Family Therapist Licensure In-State

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Mftapp Application for Marriage and Family Therapist Licensure In-State

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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
IN-STATE APPLICATION
FOR LICENSURE AND EXAMINATION
Please note:
This application is for individuals who need their hours of supervised
experience to be evaluated in order to qualify for the LMFT Clinical
Examination
Your hours of experience must be gained within the six (6) years prior
to the date your application is received by the Board
This application can be submitted before you pass the LMFT Law and
Ethics Examination
Dear In-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. Application Instructions
2. Important Information for Applicants
3. In-State Application for Licensure and Examination
4. In-State Experience Verification, Option 1*
5. In-State Experience Verification, Option 2*
6. Examination Security Agreement
BOARD OF BEHAVIORAL SCIENCES
*If you have out-of-state hours, submit an Out-of-State Experience Verification form,
available on the Board’s website.
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
APPLICATION INSTRUCTIONS
LICENSED MARRIAGE AND FAMILY THERAPIST
IN-STATE
APPLICATION FOR LICENSURE AND EXAMINATION
Submit a completed application to: Board of Behavioral Sciences
1625 North Market Blvd., Suite S200
Sacramento, CA 95834
Carefully read the following 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 the application
being deficient or delayed.
A. APPLICATION
• Complete all sections of the 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: Though providing your email address is optional, the Board
strongly recommends submission to facilitate communication.
B. PHOTOGRAPH
Should measure approximately 2" X 2" and be taken within 60 days of the filing of this
application. Photograph must be of passport quality of your head and shoulders only.
Attach the photograph to the application in the space provided.
C. EXAMINATION SECURITY AGREEMENT
The Examination Security Agreement must be completed and signed in ink. Failure to
complete this agreement will delay your eligibility to take the examinations.
37A-318 (Revised 01/2019) 1
D. FEE
Submit a $200.00 check or money order made payable to the Behavioral Sciences
Fund. The $200.00 fee consists of a $100.00 application fee (for evaluating your
experience and coursework), and a $100.00 examination fee. The application fee is
NOT REFUNDABLE. Note: You will not be eligible to take the Clinical Exam until you
have passed the LMFT California Law and Ethics Exam (or the former LMFT
Standard Written Exam).
E. VERIFICATION OF EXPERIENCE
Supervised experience must total at least two (2) years (104 supervised weeks) and
3,000 hours, obtained within the six (6) years immediately preceding the date on
which your Application for Licensure and Examination is received by the Board. Up to
1,300 hours may be gained prior to the issuance of your degree. You must comply
with all of the following:
1) EXPERIENCE VERIFICATION FORMS: Each supervisor of your experience
hours must verify your experience. An In-State Experience Verification form is
provided in this packet for this purpose. Applicants must fully qualify under Option
1 OR Option 2. There is no “mixing and matching” between the two options
when calculating hours.
Older form versions that have already been signed will continue to be accepted
for either option. Use separate forms for each supervisor and each employer as
follows:
• Use the “OPTION 1” form if you wish to submit all of your hours under the
streamlined method/categories. The Board will accept all versions of the
Experience Verification forms under this method.
• Use the “OPTION 2” form if you wish to submit all of your hours under the
multiple categories method. All hours must be recorded on an Experience
Verification form that contains the multiple categories.
Personal Psychotherapy:
Document any “personal psychotherapy” received on #14 of the application
form (may include group, marital or conjoint, family, or individual). A separate
verification is not required. Personal psychotherapy must have been obtained
within the six (6) years immediately preceding the date on which your
Application for Licensure and Examination is received by the Board.
“Weekly Summary” forms CANNOT be accepted in place of the Experience
Verification form. Do not submit unless specifically requested by the Board.
2) VERIFY PRE-DEGREE AND POST-DEGREE EXPERIENCE SEPARATELY:
Your pre-degree and post-degree experience must be submitted on separate
Experience Verification forms.
37A-318 (Revised 01/2019) 2
3) WORKSHOPS, SEMINARS, TRAINING AND CONFERENCES: If you completed
any of these activities as part of your supervised experience, include those hours
on your Experience Verification forms. Do not submit other proof of completion.
4) W-2 FORMS (ONLY required for experience as an ASSOCIATE): If you were
employed while an Associate, you must submit copies of your W-2s for each year
you are claiming and for each employer. If W-2s are 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 your verification of experience, an explanation is required.
5) VOLUNTEER LETTER (ONLY required for experience as an ASSOCIATE): If you
volunteered while an Associate, a letter from your employer is required indicating
your voluntary status during the dates reported on your Experience Verification.
Ensure that the letter states the time frame (date range) during which you
volunteered. A sample letter is available on the Board’s website.
6) SUPERVISOR RESPONSIBILITY STATEMENT: Submit the original Supervisor
Responsibility Statement forms signed by each of your supervisors.
F. REQUIRED COURSEWORK
If you entered a degree program prior to August 1, 2012, submit proof of completion
of the courses listed below and on the next page (unless identified on your transcript
previously submitted for Associate registration).
REQUIRED COURSEWORK
Course
Length
Content Required
1. Child Abuse
Assessment and
Reporting
degree program prior to
08/01/2012*
7 hours
Must be based on
California law. See
BPC** section 28
2. Human Sexuality
degree program prior to
08/01/2012*
10 hours
BPC section 25 and 16
CCR*** section 1807
3. Alcoholism and
Chemical Substance
Abuse and Dependency
degree program prior to
08/01/2012*
15 hours
16 CCR section 1810
4. Aging, Long Term Care
and Elder/Dependent
Adult Abuse
degree program prior to
10 hours
BPC section 4980.39
Continued on next page
37A-318 (Revised 01/2019) 3
REQUIRED COURSEWORK (continued)
Course
Required of:
Length
Content
Required
5. Spousal/Partner
Abuse Assessment,
Detection and
Intervention
Applicants who entered
a degree program
between 01/01/1995
and 08/01/2012*
• No specific number of hours
if entered degree program
before 12/31/03, but must
cover assessment,
detection and intervention
• 15 hours if entered a degree
program after 1/1/2004
BPC section
4980.41
6. Psychological
Testing
Applicants who entered
a degree program
between 01/01/2001
and 08/01/2012*
2 semester units or
3 quarter units
BPC section
4980.41
7. Psychopharmacology
Applicants who entered
a degree program
between 01/01/2001
and 08/01/2012*
2 semester units or
3 quarter units
BPC section
4980.41
8. California Law and
Professional Ethics
Applicants who entered
a degree program prior
to 08/01/2012*
2 semester units or
3 quarter units
BPC section
4980.41
*This topic continues to be required for applicants who entered a degree program after
08/01/2012, but content is now provided within the degree program, and proof of course
completion not required.
** Business and Professions Code *** Title 16, California Code of Regulations
G. BACKGROUND QUESTIONS (A - D)
If you answered YES to application questions A, B, C or D, complete and submit a
Background Statement. Please be aware that your processing time will be longer
than normal and will also be dependent on your providing all information required by
the Board.
37A-318 (Revised 01/2019) 4
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
IMPORTANT INFORMATION FOR APPLICANTS
SUBMITTING AN APPLICATION
FOR LMFT LICENSURE AND EXAMINATION
1. VETERANS HONORABLY DISCHARGED RECEIVE EXPEDITED REVIEW
The Board is required to expedite the licensure process for an applicant who is a
honorably discharged veteran of the U.S. Armed Forces pursuant to Business and
Professions Code section 115.4. Download the request form from the Board’s website
and include it ON TOP OF your application.
2. SPOUSES OR PARTNERS OF PERSONS ON ACTIVE MILITARY DUTY RECEIVE
EXPEDITED REVIEW
The Board is required to expedite the licensure process for an applicant whose spouse or
partner or partner by way of another legal union, is an active duty member of the U.S.
Armed Forces and meets other criteria pursuant to Business and Professions Code
section 115.5. Download the request form from the Board’s website and include it ON
TOP OF your application.
3. RECEIPT OF APPLICATION
If you would like to know whether the Board has received your application, the Board
recommends that you mail your application in a manner that includes tracking. You can
also check with the bank to see if your check or money order has been cashed. Another
option is to include a self-addressed stamped postcard or envelope ON TOP OF your
application, which will be mailed back to you upon receipt.
4. 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:
• Applicant does not submit evidence that he or she has cleared the deficiencies
specified in the deficiency letter within one (1) year from the date of the initial deficiency
letter.
• Applicant fails to sit for examination within one (1) year after being notified of eligibility.
• Applicant fails 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
37A-317 (Revised 01/2019) 1
required documentation, as well as meet all current licensure requirements in effect at the
time the new application is submitted.
5. 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.
6. REQUESTS FOR TESTING ACCOMMODATIONS
Pursuant to Title II of the Americans with Disabilities Act (ADA) and California law, the
Board will provide reasonable accommodations to qualified candidates with mental
disabilities, physical disabilities, or other qualifying medical conditions which limit a major
life activity or a major bodily function.
Accommodations may be made to the regular testing environment, and auxiliary aids and
services may be provided that allow applicants with disabilities to demonstrate their true
aptitude. However, the Board will not provide accommodations that fundamentally alter the
measurement of the skills or knowledge the examination is intended to test.
• Candidates do NOT need to request an accommodation for a physically accessible
exam site, as all sites are physically accessible.
• A testing accommodation CANNOT be provided at the examination site unless prior
approval has been granted. DO NOT SCHEDULE YOUR EXAMINATION UNTIL
YOUR ACCOMMODATION HAS BEEN APPROVED. Otherwise, the testing vendor
will be unable to provide your requested accommodation.
• A candidate who seeks an accommodation is responsible for submitting the request
and providing reasonable documentation to substantiate the need for accommodation.
Refer to the Candidate Request for Testing Accommodation packet, available on the
Board’s website, for instructions on how to submit your request, or contact the Board
directly to request the packet be mailed to you.
PROCESSING TIME WILL VARY DEPENDING ON THE VOLUME OF REQUESTS
RECEIVED FROM APPLICANTS.
37A-317 (Revised 01/2019) 2
7. 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 thereunder, are available from the ADA coordinator.
8. EXAM REQUIREMENT FOR RENEWAL OF ASSOCIATE REGISTRATION
If you continue to hold an Associate registration after submitting your Application for
Licensure and Examination, you will be required to take the LMFT California Law and
Ethics Exam in order to renew (unless you have already passed this exam). A
registration will not be renewable until the exam has been taken. For more information,
see the Exams tab on the Board’s website.
9. INITIAL LICENSE APPLICATION AND FEE
Once you have passed both examinations, you will be required to submit a Request for
Initial License form, along with the fee indicated on the form, in order to have your license
issued. This form is available on the Board’s website, or you may request one be mailed
to you.
10. 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.
11. STATUTES AND REGULATIONS
To obtain a copy of the Board’s Statutes and Regulations, please access it from the
Board’s website or submit a written request to the Board.
12. MANDATORY REPORTER
Under California law each person licensed by the Board is a “mandated reporter” for both
child, elder and/or dependent adult abuse or neglect. 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 his or her
professional capacity or within the scope of his or her 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.
37A-317 (Revised 01/2019) 3
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, 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.
13. 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, your 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.
14. STATE TAX OBLIGATION – EFFECTIVE JULY 1, 2012
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 applicant does not pay his or her state tax obligation, his or her
license or registration may be suspended.
15. 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 and Examination 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.
37A-317 (Revised 01/2019) 4
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.
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-317 (Revised 01/2019) 5
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
IN-STATE APPLICATION FOR
LICENSURE AND EXAMINATION
For applicants with a California degree ONLY
$200 FEE MUST ACCOMPANY THIS FORM
Make check payable to - Behavioral Sciences Fund
Type or print clearly in ink
1. Legal Name* Last
First
Middle
2. If you have ever been known by another name, list the full name(s) and
dates of use below (attach additional names and dates):
ATTACH A
PHOTOGRAPH TAKEN
WITHIN 60 DAYS
OF FILING
THIS APPLICATION
(Head and
Shoulders Only)
Full Name
Dates of Use (from/to)
Full Name
Dates of Use (from/to)
3. Address of Record** Number and Street
City
State
Zip Code
4. Business Telephone
5. Residence Telephone
6. E-Mail Address (OPTIONAL)
7. Birth Date: mm/dd/yyyy
8. SSN or ITIN***
9. Qualifying Degree Title
10. Name of School, College or University
11. Have you ever served in the United States Armed Forces
Yes, Currently No
or the California National Guard? (OPTIONAL)
Yes, Previously
37A-300 (Revised 01/2019) Page 1 of 5
Applicant Name: Last
First
Middle
Yes
No
12. Have you ever applied for or been issued a license, registration or
certificate to practice marriage and family therapy or any other healing art in
California or any other state?
If YES, provide the information requested below (continue on an additional
sheet if needed):
State
Type of License, Registration
or Certificate
License, Registration
or Certificate Number
Date Issued
Status
13. Under which method are you requesting your supervised
experience hours be evaluated?
Note: You must fully qualify under either Option 1 or Option 2.
Option 1 (New Method)
Option 2 (Pre-existing
Method)
There is no “mixing and matching” between the two options.
See application instructions for more information.
14. IF you selected Option 2 above, and you wish to claim hours of Personal Psychotherapy
received, complete the following:
Name of Therapist
License
Number
Start Date
End Date
Total Hours
____ X 3 = _____
____ X 3 = _____
____ X 3 = _____
37A-300 (Revised 01/2019) Page 2 of 5
Applicant Name: Last
First
Middle
BACKGROUND QUESTIONS
A. Have you been convicted of, pled guilty to, or pled nolo
contendere to any misdemeanor or felony in the United
States, its territories, or a foreign country? Convictions
dismissed under sections 1203.4, 1203.4a, or 1203.41 of
the Penal Code (or equivalent non-California law) must be
disclosed. If you have obtained a dismissal of such a
conviction, submit a certified copy of the court order.
DO NOT INCLUDE:
• Convictions prior to your 18
th
birthday, unless you were
charged as an adult;
• Charges dismissed under section 1000.3 of the Penal
Code;
• Convictions under sections 11357(b), (c), (d), (e) or
section 11360(b) of the Health and Safety Code which
are two (2) years or older;
• Traffic violations for which a fine of $500 or less was
imposed; or
• Infractions
B. Is any criminal action pending against you, or are you
currently awaiting judgment and sentencing following entry
of a plea or jury verdict?
DO NOT INCLUDE:
• Traffic violations for which a fine of $500 or less was
imposed; or
• Infractions
Yes
No
If YES, you must complete Part A
of the Background Statement form,
available on the Board’s website.
You must answer “Yes” even if the
conviction(s) have been previously
reported to the Board. In a written
statement, please list each
conviction, including the date(s) of
the conviction(s). It is not
necessary for you to resubmit
documentation previously on file.
Yes
No
If YES, you must complete Part B of
the Background Statement form,
available on the Board’s website.
37A-590 (Revised 01/2019) Page 3 of 5
Applicant Name: Last
First
Middle
C. Have you ever been denied a professional license
(“license” includes registrations, certificates, or other
means to engage in practice) OR had a professional
license 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?
D. Does your current use of chemical substances in any way
impair or limit your ability to safely interact with the public
while engaging in the practice of marriage and family
therapy?
Yes
No
If YES, you must complete Part C
of the Background Statement form,
available on the Board’s website.
You must answer “Yes” even if you
have previously reported it to the
Board. In a written statement,
please indicate the type of
professional license that was
denied, suspended, disciplined, or
surrendered, including the date(s)
of the denial, suspension,
disciplinary action, or surrender. It
is not necessary for you to resubmit
documentation previously on file.
Yes
No N/A
If YES, you must complete Part D of
the Background Statement form,
available on the Board’s website.
NOTE: Knowingly providing false information or omitting pertinent information may be
grounds for denial of this application. The board has the right to refuse to issue any
registration or license, or may suspend or revoke the license or registration of any registrant
or licensee if the applicant secures the license or registration by fraud, deceit, or
misrepresentation.
Signature of Applicant: ______________________________________ Date:_____________
37A-300 (Revised 01/2019) Page 4 of 5
* 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. If you do not want your
home or work address available to the public, use an alternate mailing address.
*** 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.
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.
37A-300 (Revised 01/2019) Page 5 of 5
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
IN-STATE EXPERIENCE VERIFICATION
OPTION 1 –STREAMLINED METHOD
This form is to be completed by the applicant’s California supervisor and submitted by the applicant with his or
her Application for Licensure and Examination. All information on this form is subject to verification.
• Use this “Option 1” form to report hours under the streamlined method
The hours
• Use separate forms for pre-degree and post-degree experience
reported on this
• Use separate forms for each supervisor and each employment setting
form were earned
• Ensure that the form is complete and correct prior to signing
(mark one):
• Provide an original signature and have the supervisor initial any changes
Pre-Degree
Post-Degree
• Do not submit Weekly Summary forms unless specifically requested
APPLICANT NAME:
Last
First
Middle
Associate Number
AMF
SUPERVISOR INFORMATION:
Supervisor’s Last Name
First
Middle
Business Phone
Email Address (OPTIONAL)
License Type
License Number
Date First Licensed*
• Physicians: Were you certified in Psychiatry by the American Board of Psychiatry and Neurology during the
entire period of supervision? N/A No Yes: Date Certified: __________ Cert. #: ____________
• LPCCs: Did you meet the qualifications to treat couples and families during the entire period of supervision, as
specified in California law? N/A No Yes: Date qualifications were met: __________________
*If licensed for less than two years on the first date of experience claimed, also provide out-of-state license information.
APPLICANT’S EMPLOYER INFORMATION:
Name of Applicant’s Employer
Business Phone
Address Number and Street
City
State
Zip Code
37A-301 (Revised 01/2019) 1 of 2
Applicant: Last
First
Middle
EMPLOYER INFORMATION (continued):
1. Was this experience gained in a setting that lawfully and regularly provides mental health
counseling or psychotherapy?
2. Was this experience gained in a private practice setting?
3. Was this experience gained in a setting that provided oversight to ensure that the
applicant’s work meets the experience and supervision requirements and is within the
scope of practice?
4. For hours gained as an Associate ONLY: Was the applicant receiving pay?
If YES, attach a copy of the applicant’s W-2 statement for each year experience is
claimed. If a W-2 has not yet been issued for this year, attach a copy of the current
paystub. If applicant volunteered, submit a letter from the employer verifying volunteer
status.
EXPERIENCE INFORMATION:
Yes No
Yes
Yes
No
No
Yes
N/A
No
(pre-degree
experience)
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:
Logged 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
Logged Hours
Individual or Triadic
Group (group contained no more than 8 persons)
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.
Supervisor Signature: _______________________________________ Date: ______________
37A-301 (Revised 01/2019) 2 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
IN-STATE EXPERIENCE VERIFICATION
OPTION 2 –MULTIPLE CATEGORY METHOD
This form is to be completed by the applicant’s California supervisor and submitted by the applicant with his or her
Application for Licensure and Examination. All information on this form is subject to verification.
• Use this “Option 2” form for reporting hours under the multiple category method
• Use separate forms for pre-degree and post-degree experience
• Use separate forms for each supervisor and each employment setting
The hours on this
• Make sure that the form is complete and correct prior to signing
form were earned
(mark one):
• Provide an original signature and have the supervisor initial any changes
Pre-Degree
• For your hours to qualify under “Option 2,” your Application for Licensure and
Post-Degree
Examination MUST be postmarked by December 31, 2020.
APPLICANT NAME:
Last
First
Middle
Associate Number
AMF
SUPERVISOR INFORMATION:
Supervisor’s Last Name
First
Middle
License Type
License Number
Date First Licensed*
Business Phone
• Physicians: Were you certified in Psychiatry by the American Board of Psychiatry and Neurology during the
entire period of supervision? N/A No Yes: Date Certified: __________ Cert. #: ____________
• LPCCs: Did you meet the qualifications to treat couples and families during the entire period of supervision, as
specified in California law? N/A No Yes: Date qualifications were met: __________________
*If licensed for less than two years on the first date of experience claimed, also provide out-of-state license information.
APPLICANT’S EMPLOYER INFORMATION:
Name of Applicant’s Employer
Business Phone
Address Number and Street
City
State
Zip Code
37A-302 (Revised 01/2019) 1 of 2
Applicant: Last
First
Middle
EMPLOYER INFORMATION (continued):
1. Was this experience gained in a setting that lawfully and regularly provides mental health
Yes No
counseling or psychotherapy?
2. Was this experience gained in a private practice setting?
Yes No
3. Was this experience gained in a setting that provided oversight to ensure that the applicant’s
Yes No
work meets the experience and supervision requirements and is within the scope of practice?
4. For hours gained as an Associate ONLY: Was the applicant receiving pay?
Yes No
If YES, attach a copy of the applicant’s W-2 statement for each year experience is claimed.
N/A
If a W-2 has not yet issued for this year, attach a copy of the current paystub. If applicant
(pre-degree
volunteered, submit a letter from the employer verifying volunteer status.
experience)
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. Show only those hours logged on the Weekly Summary of Experience Hours form*:
Logged Hours
a. Individual Psychotherapy (No minimum or maximum hours required)
b. Couples, Families, and Children (Minimum 500 hours**)
• Of the hours recorded on line 3.b, how many actual hours were gained providing
conjoint couples and family therapy?
c. Group Therapy or Counseling (Maximum 500 hours)
d. Telehealth Counseling (Maximum 375 hours)
e. Workshops, Seminars, Training sessions, or Conferences*** (Maximum 250 hours)
f. Administering and evaluating psychological tests of counselees, writing clinical reports
and progress or process notes
g. Client-Centered Advocacy
4. Face-to-Face Supervision***:
Hours Per Week
Logged Hours
a. Individual or Triadic
b. Group (group contained no more than 8 persons)
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.
Supervisor Signature: _____________________________________________ Date: ______________
* Do not submit your “Weekly Summary” forms unless specifically requested by the Board
** Up to 150 hours treating couples and families may be double-counted toward the 500 total required
*** These categories when combined with credited Personal Psychotherapy shall not exceed 1,000 hours
37A-302 (Revised 01/2019) 2 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
Telephone: (916) 574-7830 TTY: (800) 326-2297
www.bbs.ca.gov
EXAMINATION SECURITY AGREEMENT
California statutes authorize state agencies to maintain the security of their licensing
examinations. Section 123 of the Business and Professions Code states:
“It is a misdemeanor for any person to engage in any conduct which subverts or attempts
to subvert any licensing examination or the administration of an examination…”
Conduct that subverts or attempts to subvert a licensing examination includes:
• Removal of examination materials from the examination room;
• Unauthorized reproduction of any and all portions of a licensing examination;
• Acquisition of examination materials before, during, or after the examination;
• Preparation or instruction of applicants for the examination with the aid of examination
material;
• Paying or using professional examination takers to reconstruct any portions of a licensing
examination;
• Buying, selling, or receiving future, current, or previously administered examination materials;
• Communicating with other candidates during the examination or permitting one’s answers to
be copied by another candidate;
• Impersonating another candidate or having another person take the examination on one’s
behalf.
A person found guilty of any of these acts is liable for damages sustained by the agency
administering the examination in an amount not to exceed $10,000, plus the costs of
litigation. In addition, a board may deny, suspend, revoke, or otherwise restrict the license
of an applicant or a licensee who has violated the above.
COMPLETE THIS SECTION
I have read and fully understand the above requirements and hereby certify that I am the
person named below who applied for licensure with the Board of Behavioral Sciences.
License Application Type:
LCSW MFT LEP LPCC
Candidate’s Name:
(print)
Last First Middle
Date of Birth:
Candidate’s
Signature:
Date
37A-640 (Rev. 12/2015)
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Mftapp Application for Marriage and Family Therapist Licensure In-State

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Completed 14 May 2020

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