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The 37A 301A form is an essential document for individuals seeking licensure as Marriage and Family Therapists in California. This form serves as a verification tool for the applicant's in-state experience, specifically under the streamlined method, known as Option 1. It must be completed by the applicant's supervisor and submitted alongside the Application for Licensure and Examination. The form requires detailed information about the applicant's experience, including whether the hours claimed were pre-degree or post-degree, and it emphasizes the importance of accurate reporting. Supervisors must provide their credentials, including license type and number, and answer specific questions regarding the qualifications to treat couples and families. Additionally, the form seeks to confirm that the experience was gained in a proper setting, with oversight to ensure compliance with the required standards. It also mandates the inclusion of supporting documentation, such as W-2 statements for paid positions or verification letters for volunteer work. The 37A 301A form plays a crucial role in ensuring that applicants meet the necessary experience requirements before they can proceed with their licensing journey.

Preview - 37A 301A Form

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STATE OF CALIFORNIA BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY Governor Edmund G. Brown Jr.
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
LICENSED MARRIAGE AND FAMILY THERAPIST
IN-STATE EXPERIENCE VERIFICATION
OPTION 1 NEW 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 NEW streamlined method
Use separate forms for pre-degree and post-degree experience
Use separate forms for each supervisor and each employment setting
Ensure that the form is complete and correct prior to signing
Provide an original signature and have the supervisor initial any changes
Do not submit Weekly Summary forms unless specifically requested
The hours
reported on this
form were earned
(mark one):
Pre-Degree
Post-Degree
APPLICANT NAME:
Last
First
Middle
Intern Number
IMF
SUPERVISOR INFORMATION:
Supervisor’s Last Name
First
Middle
Email Address (OPTIONAL)
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?
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 you met the qualifications: ______________
APPLICANTS EMPLOYER INFORMATION:
Name of Applicant’s Employer
Business Phone
Address Number and Street
City
State
Zip Code
37A-301 (Revised 04/2017) 1 of 2
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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 Intern 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 No
Yes No
Yes No
N/A
(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
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.
Signature of Supervisor: _______________________________________ Date: ______________
37A-301 (Revised 04/2017) 2 of 2

Document Specifics

Fact Name Description
Purpose The 37A 301A form is used by applicants for licensure as Licensed Marriage and Family Therapists in California to verify their supervised experience.
Submission Requirements This form must be completed by the applicant’s supervisor and submitted along with the Application for Licensure and Examination.
Experience Reporting Applicants must report hours separately for pre-degree and post-degree experiences, ensuring accuracy before submission.
Governing Law The use of this form is governed by the California Business and Professions Code, specifically relating to the licensure of mental health professionals.

37A 301A: Usage Instruction

After completing the 37A 301A form, the applicant must submit it along with their Application for Licensure and Examination. It is important to ensure that all information is accurate and complete before submission. This will help in the verification process and avoid any potential delays.

  1. Obtain the 37A 301A form from the Board of Behavioral Sciences website or through your supervisor.
  2. Fill in the applicant's name, including last, first, and middle names, along with the intern number.
  3. Provide the supervisor's information, including their last name, first name, middle name, business phone, email address (optional), license type, license number, state, and the date they were first licensed.
  4. Indicate whether the supervisor is a physician certified in Psychiatry or an LPCC by answering the relevant questions and providing certification dates if applicable.
  5. Complete the applicant’s employer information, including the name of the employer, business phone, and address (number, street, city, state, zip code).
  6. Answer the questions regarding the setting where the experience was gained, ensuring to check "Yes" or "No" as appropriate.
  7. For Interns, indicate whether the applicant received pay and attach necessary documents such as W-2 statements or a letter verifying volunteer status.
  8. Fill in the dates of experience being claimed, specifying the start and end dates in mm/dd/yyyy format.
  9. State the number of weeks of supervised experience being claimed.
  10. Log the total hours of experience, including direct counseling and non-clinical experience, ensuring to meet the minimum and maximum requirements.
  11. Complete the supervision details, including the number of face-to-face hours logged for individual and group supervision.
  12. Have the supervisor sign and date the form, ensuring any changes are initialed by them.

Learn More on 37A 301A

What is the purpose of the 37A 301A form?

The 37A 301A form is used by applicants seeking licensure as a Marriage and Family Therapist in California. It serves as a verification tool for the applicant's supervised experience, which is a crucial requirement for licensure. The form must be completed by the applicant's supervisor and submitted alongside the application for licensure and examination. This ensures that the hours of experience claimed are documented and verified by a qualified supervisor.

Who needs to complete the 37A 301A form?

Only the applicant's California supervisor needs to complete the 37A 301A form. This includes supervisors who have directly overseen the applicant's clinical experience. It is important to note that separate forms are required for each supervisor and each employment setting. Additionally, the form must be filled out accurately and signed by the supervisor, with any changes initialed to maintain authenticity.

What information is required on the 37A 301A form?

The form requires various details to ensure proper verification of the applicant's experience. Key information includes:

  1. Applicant's name and intern number.
  2. Supervisor's name, contact information, and license details.
  3. Employer's name and address where the experience was gained.
  4. Dates of the experience and total weeks claimed.
  5. Details on the type of counseling experience, including hours logged for direct counseling and supervision.

All information must be accurate, as any false or omitted details could lead to denial of the application.

What happens if the information on the 37A 301A form is incorrect?

If the information provided on the 37A 301A form is found to be incorrect or misleading, it can have serious consequences. The Board of Behavioral Sciences may deny the application for licensure. Additionally, if a licensee is found to have assisted an applicant in obtaining a license through fraud or misrepresentation, disciplinary actions may be taken against them. Therefore, it is vital for both the applicant and supervisor to ensure that all details are complete and accurate before submission.

Common mistakes

Completing the 37A 301A form can be a crucial step in obtaining licensure as a Marriage and Family Therapist in California. However, many applicants make common mistakes that can delay or jeopardize their application. Understanding these pitfalls can help ensure a smoother process.

One frequent error is failing to use separate forms for different types of experience. The instructions clearly state that pre-degree and post-degree experiences require distinct forms. Ignoring this guideline can lead to confusion and may result in the rejection of your application.

Another mistake is not providing complete and accurate information. Each section of the form must be filled out thoroughly. Incomplete or incorrect details can raise red flags during the verification process, potentially causing delays. Always double-check your entries before submission.

Some applicants neglect to secure an original signature from their supervisor. The form requires a supervisor's signature, and any changes must be initialed. Submitting a form without this crucial step can render it invalid, so ensure that your supervisor signs and initials any modifications.

Additionally, applicants often forget to attach necessary documentation. For instance, if the applicant was paid during their internship, a W-2 form or current paystub is required. If the experience was voluntary, a letter from the employer confirming this status must be included. Missing these documents can lead to complications.

Another common oversight involves the experience verification questions. Applicants sometimes fail to answer all questions regarding the nature of their experience. Questions about whether the experience was gained in a lawful setting or whether the applicant received supervision are vital. Incomplete answers can signal a lack of attention to detail.

Moreover, failing to log hours accurately is a significant issue. The form requires specific details about the total hours of experience, including direct counseling and non-clinical hours. Misreporting these figures can lead to serious consequences, including the denial of your application.

Lastly, many applicants overlook the importance of the date. Each section requires accurate dating, especially the supervisor's signature. An incorrect date can create confusion and may raise questions about the timeline of your experience.

By being aware of these common mistakes, applicants can take proactive steps to avoid them. Careful attention to detail and following the guidelines can make a significant difference in the application process.

Documents used along the form

When applying for licensure as a Marriage and Family Therapist in California, the 37A 301A form is a crucial document. However, several other forms and documents often accompany it to ensure a complete application. Here’s a brief overview of some of these important documents.

  • Application for Licensure and Examination: This is the primary application form that applicants submit to the Board of Behavioral Sciences. It includes personal information, educational background, and details about supervised experience.
  • Weekly Summary Forms: These forms track the applicant's weekly hours of supervised experience. While they are not submitted with the 37A 301A form unless specifically requested, they are essential for maintaining accurate records.
  • W-2 Statements: If the applicant received payment during their internship, they must provide W-2 forms for each year of claimed experience. This documentation verifies employment and income.
  • Pay Stubs: In cases where W-2 forms are not yet available, recent pay stubs can serve as proof of employment. They should be attached if the applicant was paid for their supervised hours.
  • Verification of Volunteer Status: If the applicant volunteered, a letter from the employer confirming this status is necessary. This document helps clarify the nature of the experience claimed.
  • Supervisor’s License Verification: A copy of the supervisor’s license may be required to ensure that they are qualified to provide supervision. This adds credibility to the applicant’s experience.

Each of these documents plays a vital role in the licensure process. Ensuring that all forms are complete and accurate can help streamline your application and avoid delays. Always double-check that you have included everything needed before submitting your application.

Similar forms

The 37A 301A form, used for verifying in-state experience for Licensed Marriage and Family Therapists in California, shares similarities with the California Board of Behavioral Sciences’ 37A 301B form. The 301B form is also designed for reporting supervised experience but focuses on the post-degree experience of applicants. Both forms require detailed information about the applicant’s supervisor and their experience, ensuring that applicants meet the necessary qualifications for licensure. Additionally, the 301B form emphasizes the importance of accurate reporting and provides a structured format for documenting hours worked, similar to the 301A.

Another related document is the 37A 301C form, which is specifically used for reporting hours accrued in a group setting. Like the 301A, the 301C form requires the supervisor’s verification and signature, highlighting the importance of supervision in the licensure process. Both forms aim to ensure that applicants receive the appropriate level of oversight during their training, and they both necessitate detailed information about the applicant’s work environment and the nature of the experience gained.

The 37A 301D form is also comparable, as it is utilized for reporting hours obtained through volunteer experience. This form, like the 301A, requires confirmation from the supervisor regarding the applicant’s work and the setting in which the experience was gained. The primary similarity lies in the verification process, where both forms require original signatures and emphasize the need for accurate reporting to maintain the integrity of the licensure process.

In addition, the 37A 301E form serves a similar purpose but is tailored for applicants who have completed their experience outside of California. This form also requires supervisor verification and detailed reporting of hours worked. Both the 301A and 301E forms underscore the significance of supervision and provide a structured way to document the applicant's qualifications, ensuring that all necessary criteria for licensure are met.

The 37A 301F form, which is used for reporting experience gained in a school setting, is another document that parallels the 301A. Both forms require comprehensive information about the applicant’s experience and the supervising professional. They share a common goal: to verify that the applicant has received adequate training and supervision, whether in a clinical or educational environment, thus preparing them for successful licensure.

Furthermore, the 37A 301G form is similar in that it is used for applicants who have received their training through an internship. This form, like the 301A, requires detailed reporting of hours worked under supervision and emphasizes the need for accurate documentation. The verification process remains a crucial component in both forms, reinforcing the necessity for thorough oversight in the training of future licensed professionals.

The 37A 301H form is another related document, specifically for those who have completed their experience in a community mental health setting. This form parallels the 301A by requiring detailed information about the applicant's hours and the supervising professional. Both documents aim to ensure that applicants have met the required standards for experience and supervision, thereby supporting their journey toward licensure.

Additionally, the 37A 301I form is comparable, as it is designated for reporting hours accrued through telehealth services. This modern adaptation reflects the evolving nature of mental health services while maintaining the core requirements for verification and documentation present in the 301A. Both forms emphasize the importance of supervision and accurate reporting, ensuring that applicants are well-prepared for licensure.

Finally, the 37A 301J form is similar in that it is used for applicants who have completed their experience in a private practice setting. Like the 301A, this form requires detailed information regarding the applicant's hours, the supervising professional, and the nature of the experience gained. Both documents serve to verify that the applicant has received the necessary training and supervision, which is essential for their licensure as a Marriage and Family Therapist in California.

Dos and Don'ts

When filling out the 37A 301A form, it is essential to follow certain guidelines to ensure accuracy and compliance. Here is a list of things you should and shouldn't do:

  • Do ensure that the form is completed by the applicant’s California supervisor.
  • Do use separate forms for pre-degree and post-degree experience.
  • Do provide an original signature and have the supervisor initial any changes.
  • Do verify that all information on the form is correct before submission.
  • Don't submit Weekly Summary forms unless specifically requested.
  • Don't leave any sections of the form incomplete or ambiguous.

Adhering to these guidelines will help facilitate the processing of the application and avoid potential delays or issues.

Misconceptions

There are several misconceptions surrounding the 37A 301A form, which can lead to confusion for applicants. Understanding these misconceptions can help streamline the application process for licensure as a Marriage and Family Therapist in California.

  • Misconception 1: The form can be completed by anyone.
  • This form must be filled out by the applicant's California supervisor. It is not valid if completed by someone else.

  • Misconception 2: Only one form is needed for all experience.
  • Separate forms are required for pre-degree and post-degree experiences. Additionally, each supervisor and employment setting requires its own form.

  • Misconception 3: The form does not need to be accurate.
  • All information must be complete and correct before submission. Inaccuracies can lead to delays or denial of the application.

  • Misconception 4: Weekly Summary forms must be submitted with the 37A 301A.
  • Weekly Summary forms should not be submitted unless specifically requested. Focus on providing the required information on the 37A 301A form.

  • Misconception 5: The supervisor's signature is optional.
  • An original signature from the supervisor is mandatory. Changes made to the form must also be initialed by the supervisor.

  • Misconception 6: The form does not require any supporting documents.
  • For hours claimed as an intern, a W-2 statement or current paystub must be attached if the applicant was paid. If volunteering, a verification letter is necessary.

  • Misconception 7: The experience can be gained in any setting.
  • Experience must be gained in a setting that lawfully provides mental health counseling or psychotherapy. Private practice settings are also acceptable under specific conditions.

  • Misconception 8: The form is not subject to verification.
  • All information on the 37A 301A form is subject to verification. Providing false information can result in serious consequences, including denial of the application.

Key takeaways

  • Complete the form accurately. Ensure all information is correct before submission. Mistakes can delay your application.
  • Use the form for the new streamlined method. This is specifically designed for reporting hours of experience.
  • Separate forms are required for pre-degree and post-degree experience. This helps in organizing your qualifications clearly.
  • Each supervisor and employment setting needs its own form. This ensures that your experience is documented properly.
  • Make sure to provide an original signature from your supervisor. Initials should be added for any changes made.
  • Do not submit Weekly Summary forms unless they are specifically requested. This keeps your submission clean and focused.
  • Be aware that false information or omissions can lead to application denial. Honesty is crucial in this process.