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Get CA BBS 37A-521 2010

Suite S200 Sacramento CA 95834 Telephone 916 574-7830 TTY 800 326-2297 www. bbs. ca.gov SUPERVISORY PLAN Title 16 California Code of Regulations CCR Sections 1870. 23 a 4999. 12 h and CCR Section 1874 who assume responsibility for providing supervision to those working toward a license as a Clinical Social Worker or Professional Clinical Counselor to complete and sign the following supervisory plan. The original signed plan shall be submitted by the registrant to the board upon application for examination eligibility. STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY Governor Edmund G* Brown Jr. Board of Behavioral Sciences 1625 North Market Blvd. 1 and 1822 require all associate clinical social workers and professional clinical counselor interns and licensed mental health professionals acceptable to the Board as defined in Business and Professions Code Section 4996. REGISTRANT Please type or print clearly in ink. Last Middle First Registration Number State Legal name Zip Code Number and Street Address City Business Telephone Residence Telephone LICENSED SUPERVISOR Please type or print clearly in ink. Name Employer Name License No Expiration Date Telephone Number Employment Setting a* Private Practice a* Governmental Entity b. Nonprofit and Charitable Corporation c* School College or University d. e. f* g. h. Licensed Health Facility Social Rehabilitation Facility/Community Treatment Facility Pediatric Day Health and Respite Care Facility Licensed Alcoholism or Drug Abuse Recovery or Treatment Facility Community Mental Health Facility Briefly describe the goals and objectives I certify that I understand the responsibilities regarding clinical supervision including the supervisor s responsibility to perform ongoing assessments of the supervisee and I declare under penalty of perjury under the laws of the State of California that the information submitted on this form is true and correct. Supervisor s Signature Date signed Registrant s Signature The original of this form must be submitted to the board upon application for examination eligibility. REGISTRANT Please type or print clearly in ink. Last Middle First Registration Number State Legal name Zip Code Number and Street Address City Business Telephone Residence Telephone LICENSED SUPERVISOR Please type or print clearly in ink. Name Employer Name License No Expiration Date Telephone Number Employment Setting a* Private Practice a* Governmental Entity b. Name Employer Name License No Expiration Date Telephone Number Employment Setting a* Private Practice a* Governmental Entity b. Nonprofit and Charitable Corporation c* School College or University d. e. f* g. h. Licensed Health Facility Social Rehabilitation Facility/Community Treatment Facility Pediatric Day Health and Respite Care Facility Licensed Alcoholism or Drug Abuse Recovery or Treatment Facility Community Mental Health Facility Briefly describe the goals and objectives I certify that I understand the responsibilities regarding clinical supervision including the supervisor s responsibility to perform ongoing assessments of the supervisee and I declare under penalty of perjury under the laws of the State of California that the information submitted on this form is true and correct. .

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