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 300 HOURS OF DIRECT CLIENT CONTACT
Authority: 1978 PA 368
THIS FORM IS REQUIRED IF YOU ARE APPLYING FOR A LIMITED LICENSE OR FOR A FULL LICENSURE AND YOU HAVE NOT
HELD A LIMITED LICENSE
A separate form must be completed by each supervisor who is verifying your Marriage and Family Therapy experience.
Print or Type
Date of Birth (MM/DD/YYYY)
Applicant’s Place of Employment (Organization Name)
Organization Street Address
Registration/License/Credential Number
Name of organization or institute where experience was obtained
Issuing jurisdiction/organization
If applicable, did the Board approve your
special supervisory situation? (if yes, list date)
Which of the following were you at the time of supervision (Check One):
a licensed marriage and family therapist a licensed master's social worker
a licensed professional counselor a physician practicing in a mental health setting
a fully licensed psychologist an approved supervisor or supervisor-in-training through the AAMFT
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. The applicant's experience was obtained in a Clinical practicum during graduate
education OR in a postgraduate marriage and family therapy institute.
I certify:
•
At least half of the direct client contact 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 my supervision over at least eight consecutive months.
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
LARA/BPL-MFT300HRS (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.
