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The 37A 301A form plays a crucial role in the licensure process for aspiring Licensed Marriage and Family Therapists in California. Designed to gather detailed information about an applicant's supervised experience, this form must be completed by the applicant's supervisor and submitted along with the Application for Licensure and Examination. Applicants can utilize the streamlined method known as "Option 1" when reporting their hours. The form serves as a verification tool, ensuring that the reported experience aligns with state requirements. Key sections of the form require meticulous attention, including supervisor and employer details, as well as precise documentation of clinical hours and settings where the experiences were gained. It is important for applicants to distinguish between pre-degree and post-degree hours and ensure that they submit separate forms for different supervisors and employment contexts. Creating a complete and accurate submission, including original signatures and initials for any corrections, is essential for a smooth licensure process. Failing to provide truthful information may lead to serious consequences, including a denial of the application or disciplinary actions against a licensee for any fraudulent representations. Thus, understanding the significance of the 37A 301A form is foundational for those looking to embark on a career in marriage and family therapy in California.

37A 301A Example

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

Business Phone

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? D N/A D No D 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? D N/A D No D Yes: Date you met the qualifications: ______________

APPLICANT’S EMPLOYER INFORMATION:

Name of Applicant’s Employer

Business Phone

Address

Number and Street

City

State

Zip Code

37A-301 (Revised 04/2017)

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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.

D Yes D No

D Yes D No D Yes D No

D Yes D No

D (preN/A-degree

experience)

EXPERIENCE INFORMATION:

 

1. Dates of experience being claimed:

 

From: __________________

To: _____________________

 

 

 

mm/dd/yyyy

 

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

Hours Per Week

Logged Hours

 

Supervision?

 

 

 

 

 

 

 

 

 

 

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)

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Form Characteristics

Fact Name Description
Purpose The 37A 301A form verifies in-state experience for Licensed Marriage and Family Therapists in California.
Governing Law The requirements are governed by California Business and Professions Code, Sections 4980-4980.4.
Submission This form must be completed by the applicant's California supervisor and submitted with the licensure application.
Experience Reporting Applicants must clearly mark whether the hours reported are pre-degree or post-degree.
Signature Requirements An original signature from the supervisor is required, along with initials on any changes made to the form.
Interview Considerations Information on the form is subject to verification by the Board of Behavioral Sciences.
Document Retention Do not submit weekly summary forms unless specifically requested by the Board.

Guidelines on Utilizing 37A 301A

Filling out the 37A 301A form requires careful attention to detail. The applicant will need to work closely with their supervisor to ensure that all information is accurately captured. Once completed, the form is to be submitted alongside the Application for Licensure and Examination.

  1. Obtain the form from the official website or your supervisor.
  2. Fill in the applicant's name and intern number at the top of the form.
  3. Provide the supervisor’s information, including their last name, first name, middle name, business phone number, and email address (if applicable).
  4. Specify the license type and license number of the supervisor, along with the date they were first licensed.
  5. Indicate whether the supervisor is certified in Psychiatry or if they meet the qualifications as an LPCC with respect to treating couples and families.
  6. Completely fill in the applicant’s employer information, including the business name, phone number, and address (street, city, state, and zip code).
  7. Answer the questions regarding the experience settings (whether it regularly provides mental health counseling, is a private practice, etc.).
  8. If the applicant was an intern and received pay, attach a W-2 statement or current paystub. If volunteering, attach a verification letter from the employer.
  9. Enter the dates of experience being claimed, including the 'from' and 'to' dates in mm/dd/yyyy format.
  10. Indicate the number of weeks of supervised experience being claimed.
  11. Fill in the total logged hours of direct counseling experience. Ensure that at least 1,750 hours are recorded and specify at least 500 hours gained in diagnosing and treating couples, families, and children.
  12. Indicate the total logged hours for non-clinical experience, ensuring not to exceed 1,250 hours.
  13. Report the hours of supervision (both individual and group) that were logged.
  14. Review the form for completeness and correctness, ensuring that the supervisor initials any changes.
  15. Sign the form where indicated, and have the supervisor sign and date it.

What You Should Know About This Form

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

The 37A 301A form is used to verify the in-state experience of applicants seeking licensure as Licensed Marriage and Family Therapists in California. This form must be completed by the applicant’s California supervisor and submitted with the application for licensure and examination.

Who should complete the 37A 301A form?

The form must be completed by the applicant's California supervisor. This ensures accurate reporting of the applicant's supervised experience, which is necessary for obtaining licensure.

What information is required from the supervisor?

The supervisor must provide their name, contact information, license type, and license number. Additionally, they must confirm whether the applicant has received supervision that meets California law requirements during the entire period of supervision.

Are there different versions of the form for pre-degree and post-degree experience?

Yes, separate forms should be used for reporting pre-degree and post-degree experience. This helps differentiate between the applicant’s training stages and ensures clarity in documentation.

What is the significance of the 'Original Signature' requirement?

An original signature ensures the authenticity of the information provided on the form. Supervisors must also initial any changes made to maintain integrity and transparency in the reporting process.

Are applicants required to submit additional documents with the form?

Yes, if the applicant was paid during their internship, they must attach a copy of their W-2 statement for each year of claimed experience. If no W-2 has been issued yet, a current pay stub should be included. For voluntary positions, a verification letter from the employer is required.

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

Providing false information or omitting significant details can lead to the denial of the licensure application. Moreover, the Board may take disciplinary action against any licensee involved in fraudulent practices concerning the application.

How many hours of experience must be claimed for licensure?

Applicants must log a minimum of 1,750 hours of direct counseling experience, which includes at least 500 hours of diagnosing and treating couples, families, and children. Up to 1,250 hours may be claimed for non-clinical experience.

What types of settings qualify for experience verification?

Experience must be gained in settings that lawfully and regularly provide mental health counseling. Oversight to ensure compliance with supervision requirements and the scope of practice is also essential for the experience to be valid.

How should the completed form be submitted?

The completed 37A 301A form should be submitted along with the applicant's Application for Licensure and Examination. Ensuring that all required information is accurate and that the form is signed is crucial for the success of the application process.

Common mistakes

Filling out the 37A 301A form can be a straightforward process, but several common mistakes can lead to delays or complications in licensure applications. One frequent error is failing to provide complete information. Applicants sometimes skip required sections or leave blanks, assuming that unspecified details are not critical. However, each area of the form is designed to gather necessary information about the applicant's supervised experience. Incomplete submissions can cause unnecessary delays in processing.

Another mistake involves misunderstanding the definition of experience categories. This form differentiates between pre-degree and post-degree experience, and applicants often choose the incorrect category. Choosing the wrong option could lead to a miscalculation of the hours needed, impacting the overall application status. It is crucial to be clear about when the experience occurred and ensure that all hours are reported accurately.

Accuracy in reporting hours is vital. Many applicants miscalculate or inaccurately log their hours of experience. This not only includes the total hours but also specific hours attributed to direct counseling versus non-clinical experience. Without diligent tracking and clear documentation, a significant portion of the required hours might go uncounted, which can jeopardize the application's success.

Failure to follow the required signature protocol is another common issue. Applicants may overlook that the supervisor must sign the form and initial any amendments made after the initial completion. An unsigned form faces immediate rejection, causing delays in the review process. Therefore, ensure that the supervisor is aware of their responsibilities and that all signatures are properly executed.

Lastly, some applicants neglect to attach necessary documentation, such as W-2 statements for paid experiences or letters verifying volunteer status. Each of these attachments supports the information provided on the form and helps substantiate claimed experience. Omitting these documents can lead to questions from the reviewing board, requiring further clarification and potentially extending the duration before licensure.

Documents used along the form

The 37A 301A form serves as essential documentation for applicants seeking licensure as Marriage and Family Therapists in California. Alongside this form, several other documents are often required to provide a complete application package. Each serves a unique purpose in verifying the applicant's professional experience and qualifications.

  • Application for Licensure and Examination: This primary document initiates the licensure process. It gathers vital information about the applicant, including personal details, educational background, and work experience.
  • Weekly Summary Forms: These forms outline the applicant's hours worked each week. They illustrate the accumulation of supervised experience during the therapeutic practice and may be requested for verification.
  • W-2 Statements: Required for reported employment hours, these documents confirm the applicant's income from their supervised position. Applicants must submit W-2s for each year they claim experience, reinforcing the claims made on the 37A 301A form.
  • Verification of Volunteer Status: If applicable, a letter from the employer verifies the applicant’s volunteer status. This document is crucial for applicants who did not receive compensation during their internship.
  • Supervision Agreement: This document details the relationship between the supervisor and the intern, outlining the supervision parameters and responsibilities. It ensures clarity regarding expectations and accountability during the supervision period.

Each of these documents contributes to a thorough assessment of the applicant's qualifications. Proper and timely submission ensures a smoother licensure process, allowing aspiring therapists to advance in their professional journey.

Similar forms

  • 37A 302A Form: Similar to the 37A 301A form, this document verifies the applicant’s hours but is specifically designed for applicants seeking licensure in Licensed Professional Clinical Counseling. Like the 301A, it requires supervisory confirmation of the applicant's experience.
  • Trainee Experience Verification Form: This form is used to document a trainee's hours and similar to the 37A 301A, it must be completed by the supervisor. It captures pre-degree and post-degree hours, ensuring all experience is well-documented.
  • Supervisor's Attestation Form: This document serves to attest to the applicant's professional experience. It reflects similar supervisory requirements as the 37A 301A form, ensuring that supervision details are disclosed and verified.
  • Intern Verification Form: This form allows interns to validate their hours of training. Parallel to the 37A 301A, it emphasizes the importance of supervisory oversight and detailed logging of hours for licensure application.
  • Clinical Experience Summary: This summary provides an overview of the applicant's clinical hours. Like the 37A 301A, it organizes experience details and underscores the supervisory element in documentation.
  • Employment Verification Form: Similar to the 37A 301A form, this document typically requires verification of employment details related to supervised experience. It confirms both the employment period and the nature of the work performed.
  • Log of Supervised Experience: This form records the weekly hours of supervision and client sessions. As with the 37A 301A, it is crucial for demonstrating compliance with the required experience criteria for licensure.

Dos and Don'ts

When filling out the 37A 301A form, it's essential to follow specific guidelines to ensure accuracy and compliance. Here’s a list of recommended practices and pitfalls to avoid.

  • Always ensure the form is complete and correct before signing. Incomplete forms may lead to delays.
  • Provide an original signature from the supervisor. Changes should be initialed.
  • Use separate forms for pre-degree and post-degree experiences.
  • Indicate whether the hours reported are pre-degree or post-degree.
  • Attach relevant documentation if claiming paid experience, such as a W-2 or current paystub.
  • Don't submit Weekly Summary forms unless specifically requested.
  • Avoid omitting crucial information; false statements may result in application denial.
  • Do not mix different supervisors or employment settings on the same form.

Misconceptions

There are several misconceptions surrounding the 37A 301A form. Understanding these can make the licensing process smoother.

  • Misconception 1: This form is optional.
  • In reality, this form is necessary for verifying in-state experience for licensure. It must be completed and submitted by your supervisor.

  • Misconception 2: The information provided does not need to be verified.
  • This is incorrect. All information on the form is subject to verification, and any inaccuracies could jeopardize your application.

  • Misconception 3: Using a single form for all experience is acceptable.
  • Each supervisor and each distinct employment setting requires its own form. This ensures clarity and proper tracking of experience.

  • Misconception 4: You can submit the form without a supervisor's signature.
  • A valid signature from your supervisor is mandatory. The form is not complete without it.

  • Misconception 5: Experience hours can be combined from pre-degree and post-degree work.
  • You must use separate forms for pre-degree and post-degree hours. Mixing them will lead to complications.

  • Misconception 6: It’s fine to submit incomplete forms.
  • Inaccurate or incomplete forms may be rejected. Double-check that all sections are filled out correctly before submission.

Key takeaways

  • Complete the form accurately. Ensure all information is precise before submission to avoid delays.
  • Use separate forms. One for pre-degree experience and another for post-degree, as well as distinct forms for each supervisor and employment setting.
  • Obtain original signatures. The supervisor must sign the form, and any changes should be initialed by them to validate accuracy.
  • Verify the setting. Confirm that the experience was gained in a qualifying mental health counseling environment to meet licensure requirements.
  • No Weekly Summary forms required. Do not submit these forms unless specifically requested; focus on providing the completed 37A 301A form instead.