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SUPERVISOR'S EVALUATION OF APPLICANT'S 1000 HOURS OF DIRECT (Michigan)

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LARA/BPL-MFT1000HRS (Rev. 9/19)
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status,
disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this
agency.
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 241-0199
www.michigan.gov/bpl
bpldata@michigan.gov
SUPERVISOR'S EVALUATION OF APPLICANT'S 1000 HOURS OF DIRECT CLIENT CONTACT
Authority: 1978 PA 368
NOTE: THIS FORM IS ONLY REQUIRED FOR FULL LICENSURE.
A separate form must be completed by each supervisor who is verifying your Marriage and Family Therapy experience.
Print or Type
Applicant’s First Name
Middle Name
Last Name
Date of Birth (MM/DD/YYYY)
Applicant’s Place of Employment (Organization Name)
Organization Street Name
City
State
Zip Code
Supervisor’s First Name
Registration/License/Credential Number
Date Issued
Level of Certification or Licensure or type of license/credential held
at time you provided supervision
Issuing jurisdiction/organization
If applicable, did the Board approve your
special supervisory situation? (If yes, list date)
CERTIFICATION AND SIGNATURE
I certify the applicant named above obtained marriage and family therapy experience under my supervision while my
license was in good standing.
My direct client contact supervision included the following:
• At least half of these hours were completed with families, couples, or other subsystems of families
physically present in the therapy room.
• At least one fifth of these hours were under supervision in which no more than one other supervisee was
present.
• The remaining hours may have been under group supervision with no more than six supervisees present.
I am certifying the applicant completed ________________ total hours of marriage and family therapy work
(total # of hours)
experience beginning on _______________________ and ending on ______________________.
(Month/Day/Year) (Month/Day/Year)
I declare that the information contained in this document is true and correct.
_____________________________________________ _________________________________
Signature and Title Date
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SUPERVISOR'S EVALUATION OF APPLICANT'S 1000 HOURS OF DIRECT (Michigan)

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Completed 9 February 2021

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