Form 37A-304 "Licensed Marriage and Family Therapist Out-of-State Experience Verification" - California

Form 37A-304 Printable Pdf
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What Is Form 37A-304?

This is a legal form that was released by the California Board of Behavioral Sciences - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2021;
  • The latest edition provided by the California Board of Behavioral Sciences;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 37A-304 by clicking the link below or browse more documents and templates provided by the California Board of Behavioral Sciences.

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Download Form 37A-304 "Licensed Marriage and Family Therapist Out-of-State Experience Verification" - California

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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
OUT-OF-STATE EXPERIENCE VERIFICATION
This form is for unlicensed applicants. It must be completed by the applicant’s out-of-state supervisor
and submitted by the applicant with their Application for Licensure. All information on this form is
subject to verification. Be sure to:
The hours
• Use separate forms for pre-degree and post-degree experience.
reported on this
form were earned
• Use separate forms for each supervisor and each employment setting.
as (mark one):
• Ensure that the form is complete and correct prior to signing.
 Pre-Degree
 Post-Degree
• Provide an original signature and have the supervisor initial any changes.
APPLICANT NAME:
Last
First
Middle
Associate Number
AMF
SUPERVISOR INFORMATION:
Email Address (OPTIONAL)
Supervisor’s Name
Telephone
License Type
License Number
State
Date First Licensed
• Physicians: Were you certified in Psychiatry by the American Board of Psychiatry and Neurology
during the entire period of supervision?
No
Yes: Date Board Certified: ___________ Certification Number: _________________
37A-304 (Revised 01/2021)
1 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
OUT-OF-STATE EXPERIENCE VERIFICATION
This form is for unlicensed applicants. It must be completed by the applicant’s out-of-state supervisor
and submitted by the applicant with their Application for Licensure. All information on this form is
subject to verification. Be sure to:
The hours
• Use separate forms for pre-degree and post-degree experience.
reported on this
form were earned
• Use separate forms for each supervisor and each employment setting.
as (mark one):
• Ensure that the form is complete and correct prior to signing.
 Pre-Degree
 Post-Degree
• Provide an original signature and have the supervisor initial any changes.
APPLICANT NAME:
Last
First
Middle
Associate Number
AMF
SUPERVISOR INFORMATION:
Email Address (OPTIONAL)
Supervisor’s Name
Telephone
License Type
License Number
State
Date First Licensed
• Physicians: Were you certified in Psychiatry by the American Board of Psychiatry and Neurology
during the entire period of supervision?
No
Yes: Date Board Certified: ___________ Certification Number: _________________
37A-304 (Revised 01/2021)
1 of 2
Applicant:
Last
First
Middle
APPLICANT’S EMPLOYER INFORMATION:
Name of Applicant’s Employer
Telephone
Address
Number and Street
City
State
Zip Code
EXPERIENCE INFORMATION:
From: __________________
To: _____________________
1. Dates of experience being claimed:
mm/dd/yyyy
mm/dd/yyyy
2. How many weeks of supervised experience are being claimed? __________ Weeks
Total Hours
3. Hours of Experience:
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
Hours Per Week
Total Hours
Supervision?
o Individual or Triadic
o Group
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. All information
on this form is subject to verification.
Signature of Supervisor: _______________________________________
Date: _____________
37A-304 (Revised 01/2021)
2 of 2
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