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The Bbs 37A 644 form is a crucial document for those seeking licensure as a Licensed Professional Clinical Counselor (LPCC) in California. Designed for applicants to verify their in-state experience, this form must be completed by a supervisor to affirm the supervised hours of practice. It requires detailed information, including applicant and supervisor identities, employment settings, and the nature of the counseling services provided. Applicants must specify if their experience occurred in approved environments, such as a private practice, hospital, or community mental health setting, all of which have distinct regulatory definitions. The form also assesses the type of experience gained, categorized by hours spent in direct psychotherapy, group therapy, and other relevant activities. Additionally, the form calls for a declaration under penalty of perjury, stressing the importance of accuracy and completeness. Since this verification is essential for examination eligibility, understanding each aspect of the Bbs 37A 644 form is vital for those pursuing this career path.

Bbs 37A 644 Example

STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES 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 PROFESSIONAL CLINICAL COUNSELOR

IN-STATE EXPERIENCE VERIFICATION

Applicant: Your supervisor must complete this form (unless experience is verified by an out-of-state licensing agency). Use a separate form for each person verifying hours of supervised experience toward licensure as a professional clinical counselor and for each employment setting. Submit this form with your application for examination eligibility.

Supervisor: You must complete this form. Make certain that this form is complete and correct prior to signing. Any change should be initialed by you and is subject to verification. Return the completed form to the applicant.

(Please type or print clearly in ink)

 

Applicant:

Last

 

 

First

 

 

 

Middle

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPERVISOR: (Please type or print clearly in ink)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Supervisor:

Last

 

First

 

Middle

 

2. Business Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Address:

Number and Street

 

 

 

City

 

 

 

 

 

 

 

State

 

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Name of Applicant’s Employer:

 

 

 

 

 

 

 

 

 

5. Business Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Employer’s Address:

Number and Street

 

 

 

City

 

 

 

 

 

 

 

State

 

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

a.

Was this experience gained in a setting that lawfully and regularly provides mental health counseling or psychotherapy?

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Was this experience gained in a private practice setting?

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Was this experience gained in a hospital or community mental health setting, as defined under California Code of Regulations

Yes

 

No

 

 

 

 

 

 

 

 

 

 

section 1820(d) as a setting that: lawfully and regularly provides mental health counseling or psychotherapy; where clients

 

 

 

 

 

 

 

 

 

 

 

 

who routinely receive psychopharmacological interventions in conjunction with psychotherapy, counseling, or psycho-social

 

 

 

 

 

 

 

 

 

 

interventions; where clients receive coordinated care that includes the collaboration of mental health providers; and is not a

 

 

 

 

 

 

 

 

 

 

 

 

private practice owned by a licensed professional clinical counselor, marriage and family therapist, a licensed psychologist, a

 

 

 

 

 

 

 

 

 

 

licensed clinical social worker, a licensed physician or surgeon, a professional corporation of any of these licensed professions

 

 

 

 

 

 

 

 

 

 

or unlicensed individuals?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

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 for the profession?

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Was the applicant either an employee or a volunteer during the dates of experience claimed?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If the applicant was an employee and receiving pay, attach a copy of the applicant’s W-2 statement for each year

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

experience is claimed. For the current year in which a W-2 has not been issued, submit a copy of a current paystub.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If applicant volunteered, a letter from the employer verifying volunteer status is required.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

Dates of the experience being claimed

From:

 

 

 

 

 

 

To:

 

 

 

 

 

 

 

 

 

 

 

 

mm/dd/yyyy

 

 

 

 

 

mm/dd/yyyy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. How many weeks of supervised experience are being claimed?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. Show only those hours of experience as logged on the weekly summary of hours form.

 

 

 

 

 

 

 

 

 

 

Total Logged Hours

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

Direct Psychotherapy (performed by the applicant; minimum 1,750 hours)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

Group Therapy or Group Counseling (maximum 500 hours)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

Telephone Counseling (maximum 250 hours)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d.

Administering and evaluating psychological tests of counselees, writing clinical reports and progress or process notes

 

 

 

 

 

 

 

 

 

 

 

 

(maximum 250 hours)*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e.

Workshops, seminars, training sessions, or conferences directly related to professional clinical counseling

 

 

 

 

 

 

 

 

 

 

 

 

(maximum 250 hours)*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f.

Client Centered Advocacy (CCA)*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

37A-644 (New 6/11)

 

 

1

 

 

 

 

 

 

 

 

 

 

 

This form may be reproduced

Applicant:Last

First

Middle

13. Face-to-face supervision*:

Hours per week

Total Logged Hours

 

 

(Range)

 

 

a.Individual

b.Group (Group supervision contained no more than eight (8) persons)

14.Supervisor License Information:

Type of License

License Number

State of Licensure

Date Originally Licensed

 

 

 

 

If M.D., were you certified in Psychiatry by the American Board of Psychiatry and Neurology during the entire period of supervision?

Yes

No

Date Board certified: _________________________

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct

Signature of Supervisor:

 

Date:

 

*When combined, these categories shall not exceed 1,250 hours of experience (BPC Section 4999.46(b)(6)).

37A-644 (New 6/11)

2

This form may be reproduced
Get Bbs 37A 644 PDF Form

Form Characteristics

Fact Name Description
Governing Agency The BBS 37A 644 form is overseen by the Board of Behavioral Sciences in California.
Application Purpose This form is required for verifying an applicant's experience hours toward licensure as a Licensed Professional Clinical Counselor.
Experience Verification The form must be completed by the applicant's supervisor to document their supervised experience hours.
Employment Settings Separate forms must be submitted for each employment setting in which the supervised experience occurred.
California Regulations Experience claimed must align with the definitions provided in the California Code of Regulations, particularly section 1820(d).
Supervisor’s Responsibilities Supervisors are urged to ensure the form is filled out accurately; any corrections should be initialed by the supervisor.
Experience Types Different types of experience can be claimed, including direct psychotherapy and group counseling, with set hour limits.
W-2 Requirement If the applicant was paid, they must attach W-2 statements for the relevant years to verify their employment.
Volunteer Verification For volunteer experience, a letter from the employer confirming the volunteer status is necessary.
Signature and Declaration The supervisor must sign and date the form, declaring the information is true under penalty of perjury in California.

Guidelines on Utilizing Bbs 37A 644

Once the Bbs 37A 644 form is filled out, it should be submitted along with your application for examination eligibility. Ensure that your supervisor completes the necessary sections accurately. This will help confirm your supervised experience as a professional clinical counselor.

  1. Begin by entering the applicant's information at the top of the form. Include the last name, first name, and middle name, followed by the Social Security Number.
  2. Next, the supervisor must provide their details in the designated section. This includes their last name, first name, and middle name.
  3. Fill in the business phone number of the supervisor.
  4. Provide the address of the supervisor's place of work, including the number and street, city, state, and zip code.
  5. Enter the name of the applicant's employer.
  6. Include the business phone number of the employer.
  7. Fill out the employer's address as in previous steps.
  8. Answer the following questions with a simple Yes or No:
    • Whether the experience was gained in a lawful setting providing mental health counseling.
    • If it was in a private practice setting.
    • If the experience was in a hospital or community mental health setting as defined in California Code.
    • Whether the applicant's work had oversight to meet experience and supervision requirements.
    • If the applicant was an employee or volunteer during the claimed experience.
  9. Indicate the dates of the experience being claimed, completing the From and To sections in mm/dd/yyyy format.
  10. State how many weeks of supervised experience are being claimed.
  11. Show only the logged hours for the following categories:
    • Direct Psychotherapy
    • Group Therapy or Counseling
    • Telephone Counseling
    • Psychological Tests and Reports
    • Workshops or Training Related to Counseling
    • Client Centered Advocacy
  12. Detail face-to-face supervision hours per week under the respective categories for individual and group supervision.
  13. The supervisor must fill out their license information, including type of license, license number, state of licensure, and date originally licensed.
  14. If applicable, indicate if the supervisor was certified in Psychiatry, and include the date board certified.
  15. Finally, the supervisor must declare the information is true under penalty of perjury and sign with the date.

What You Should Know About This Form

What is the purpose of the BBS 37A 644 form?

The BBS 37A 644 form is used for verifying the supervised experience required for applicants seeking licensure as a Licensed Professional Clinical Counselor (LPCC) in California. Supervisors must complete this form to confirm the hours of supervised experience the applicant has obtained. It is essential for ensuring that applicants meet the necessary qualifications and experience standards before they are eligible to take the licensing examination.

Who is responsible for completing the BBS 37A 644 form?

The supervisor holds the responsibility of completing the BBS 37A 644 form. This person must ensure that the information provided is complete and accurate. If adjustments are needed after signing, the supervisor should initial these changes. The completed form must then be returned to the applicant, who will submit it with their application for examination eligibility.

What specific information is required on the BBS 37A 644 form?

The form requires several pieces of information including the applicant's name and Social Security Number, details about the supervisor and their license, and the nature of the experience gained by the applicant. This includes confirmation of whether the experience was obtained in a lawful mental health setting, whether the applicant was an employee or volunteer, and specifics about the hours logged for various activities related to counseling. Proper documentation, such as W-2 forms or verification letters for volunteer status, must also be provided alongside this form as part of the application process.

How should the logged hours be reported on the BBS 37A 644 form?

Applicants must report logged hours using the specific categories outlined on the form. These categories include direct psychotherapy, group therapy, telephone counseling, and other professional activities, each with its maximum hours limit. Care must be taken to ensure that the total logged hours do not exceed the specified limits and comply with California’s regulations. This ensures transparent and accurate representation of the applicant's clinical experience.

Common mistakes

Completing the BBS 37A 644 form requires careful attention to detail. One common mistake is failing to provide accurate personal information for both the applicant and the supervisor. Ensure that names, addresses, and contact numbers are typed or printed clearly. Inaccurate information can lead to delays in processing the application.

Another frequent error involves misrepresenting the type of employment setting. It is crucial to correctly answer questions regarding whether the experience was gained in a lawfully operating mental health environment. Incomplete or incorrect answers can result in the rejection of claimed hours, affecting eligibility for licensure. Form data should align with supporting documents to avoid discrepancies.

People often forget to include required attachments, particularly proof of employment or volunteer status. Applicants must attach a W-2 statement for each claimed year of work, or a current paystub if necessary. For volunteers, a verification letter from the employer is essential. This omission can stall the entire licensure process.

Inaccurate calculations regarding the total hours of supervised experience are another prevalent issue. The form specifies maximum limits for different categories of experience. Failing to log hours correctly or including unverified hours can jeopardize the application. Review the summary of hours before submission to ensure compliance.

Many applicants overlook the necessity of the supervisor’s signature at the end of the form. This signature not only certifies the accuracy of the information but also validates the claimed experience. Without this endorsement, the form is incomplete, and the application cannot proceed.

Lastly, neglecting to check for updates in the requirements or instructions may lead to mistakes. Regulations can change, and it is vital to reference the latest guidelines provided by the Board of Behavioral Sciences. This precaution helps ensure that all necessary information is provided and that the form is filled accurately.

Documents used along the form

When applying for licensure as a Licensed Professional Clinical Counselor in California, several forms may accompany the BBS 37A 644 form. Each document plays a crucial role in verifying your qualifications and experience. Below is a list of commonly used forms that may be submitted together with the BBS 37A 644.

  • BBS 37A 643 - Supervised Experience Verification: This form is similar to the BBS 37A 644 but is specifically for those who have attained experience under different supervisors or settings. Each supervisor must fill out their own form for the applicant's records.
  • Verification of Employment Letter: This letter provides proof of the applicant's employment at the respective agency or practice. It should include dates of employment, position, and a brief description of duties performed.
  • Application for Examination Eligibility (BBS 37A 101): This application must be filled out to establish eligibility to sit for the licensing examination. It includes details about the applicant's educational background and work experience.
  • W-2 Statements: Required for applicants who were employed during their claimed experience period, these statements provide documented evidence of income received for each year of reported experience.
  • Current Paystub: When a W-2 is unavailable, a current paystub demonstrating active employment during the experience claimed may be submitted instead.
  • Letter of Verification for Volunteer Experience: If the applicant gained experience through volunteer work, this letter should come from the supervising agency confirming the applicant’s role and the nature of the experience.
  • Weekly Summary of Hours Form: This form aggregates the weekly logged hours of supervised experience and must be submitted to show compliance with the minimum hours required for licensure.

Each of these documents supports your application by providing essential information about your training and experience. It is crucial to ensure that all forms are completed accurately and submitted in a timely manner for a smooth licensure process. Proper documentation not only facilitates the review of your application but also helps in building a strong case for your qualifications as a Licensed Professional Clinical Counselor.

Similar forms

  • California BBS 37A-644 Form for Licensed Professional Clinical Counselor Experience Verification: This form is utilized by applicants seeking license as professional clinical counselors to verify their supervised experience. Much like other verification documents, it demands accurate details from both the applicant and their supervisor.

  • BBS 37A-646 Form for Registered Associate Marriage and Family Therapist Experience Verification: This document serves a similar purpose for Marriage and Family Therapist candidates. It verifies supervised experience, requiring sign-off from the candidate's supervisor and detailing the hours worked, reflecting essential experience for licensure.

  • California Board of Psychology Experience Verification Form: Candidates for licensure as psychologists must complete this form to confirm their supervised hours. It parallels the BBS 37A-644 in that it also requires specific details about the experience and supervision to ensure the necessary qualifications are met.

  • California Social Work Supervisor Verification Form: Similar to the BBS 37A-644, this form helps verify the experience of candidates seeking licensure in social work. It also stresses the importance of supervisor input regarding the applicant's work history and areas of focus during their supervised period.

  • Clinical Hours Documentation Form: This form is often used by various mental health professions to document hours of clinical practice and supervision. Like the BBS 37A-644, it requires documentation of the specific hours worked and a supervisor's signature, maintaining a clear record of experience for licensing purposes.

Dos and Don'ts

When filling out the BBS 37A 644 form, keep these important do's and don'ts in mind:

  • Do use clear and legible handwriting or type when completing the form.
  • Do ensure that each section is fully completed before submitting it.
  • Do attach required documents, such as W-2 forms or verification letters for volunteer experience.
  • Do have your supervisor carefully review their completed section for accuracy.
  • Don't leave any questions unanswered; incomplete forms may be returned or delayed.
  • Don't forget to check for consistency between the logged hours and the summary of hours form.
  • Don't hesitate to ask for clarification on any section if you are unsure how to proceed.

Taking these steps can help streamline your application process and potentially avoid unnecessary delays. It is crucial to ensure accuracy as you move forward in your journey toward licensure. Pay attention to every detail, as this form is a vital component of your professional future.

Misconceptions

Misunderstandings around the Bbs 37A 644 form can lead to confusion and may hinder the licensure process for aspiring professional clinical counselors in California. Here are ten common misconceptions addressed with care.

  • 1. The Bbs 37A 644 form is solely for licensed supervisors. This form is meant for both the supervisor and the applicant. The supervisor verifies the experience, while the applicant submits the form with their application.
  • 2. Only paid experience counts toward the required hours. Both paid and volunteer experiences are valid. The form requires verification of volunteer experience via a letter from the employer.
  • 3. The form can be signed without thorough review. It is critical that the supervisor checks for accuracy before signing. Any corrections must be initialed to ensure transparency.
  • 4. All hours logged on the form automatically qualify. Only hours accrued in approved settings and roles, as specified, count towards licensure. The criteria must be carefully followed.
  • 5. Experience gained out of state does not require this form. If the experience was not verified by an out-of-state agency, the Bbs 37A 644 form must still be completed for in-state experience.
  • 6. Group supervision is not considered valid. Group supervision can count; however, the group should consist of no more than eight persons to ensure proper oversight.
  • 7. You do not need to submit additional verification documents. If the applicant was employed and receiving pay, a W-2 form for each year should be attached. Pay stubs or verification letters may also be required.
  • 8. The total hours of experience claimed can exceed limits. The form outlines strict caps on certain types of experience, such as direct psychotherapy and group work. Exceeding these limits may not be accepted.
  • 9. Supervisors can complete the form at any time. Supervisors should complete and return the form promptly after the experience is verified, as this allows the applicant to proceed with their application.
  • 10. Any supervisor, regardless of credentials, can validate experience. The supervisor must hold a valid license in the relevant field to accurately verify and endorse the hours claimed.

Understanding these misconceptions can greatly assist applicants in navigating the licensing process with clarity and confidence.

Key takeaways

Successfully completing the Bbs 37A 644 form is crucial for applicants pursuing licensure as Licensed Professional Clinical Counselors in California. Below are key takeaways to guide applicants and their supervisors in the process.

  • Separate Forms Required: Each supervisor and employment setting requires a separate Bbs 37A 644 form. Make sure to accurately provide information for every different experience being claimed.
  • Complete and Accurate Submission: Supervisors must ensure that all sections of the form are filled out correctly. Incomplete or inaccurate forms can delay the application process.
  • Experience Verification: The form must verify that the claimed experience occurs in a lawful mental health setting. Questions related to this must be answered with precision.
  • Documentation of Employment: If the experience was gained as a paid employee, applicants should attach a W-2 statement. For volunteer experiences, a verification letter from the employer is necessary.
  • Supervision Requirements: The form specifies the total hours and types of clinical experiences required. Be mindful not to exceed the maximum allowable hours in certain categories, ensuring compliance with state regulations.

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