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Get CA BBS 37A-524a 2011-2024

Suite S200 Sacramento CA 95834 Telephone 916 574-7830 TTY 800 326-2297 www. bbs. ca.gov MARRIAGE AND FAMILY THERAPIST WEEKLY SUMMARY OF HOURS OF EXPERIENCE FOR HOURS GAINED ON OR AFTER January 1 2010 THIS FORM SHALL BE COMPLETED PURSUANT TO TITLE 16 CALIFORNIA CODE OF REGULATIONS SECTION 1833 e. STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY Governor Edmund G* Brown Jr. Board of Behavioral Sciences 1625 North Market Blvd. Use a separate log for each supervised work setting and for each status indicated below. Please type or print clearly in ink Name of MFT Trainee/Intern First Last Name of Supervisor Middle Date enrolled in graduate degree program Name of Work Setting Address of Work Setting City State Zip Number and Street Indicate the status of the hours logged Trainee Trainee in Practicum BBS File No if known Post-Degree with Application Pending for Intern Registration B P Code Section 4980. 43 h Registered Intern MFT Intern No* Supervision via video conferencing is not allowed as a trainee Note Child counseling can be logged in any appropriate category as specified by your supervisor YEAR Total Hours WEEK OF Individual Psychotherapy performed by you Couples Families and Children min* 500 hrs. Of the above CFC hours how many actual hours were gained via conjoint couples and family therapy Group Therapy or Counseling max. 500 Telemedicine max. 375 Administering evaluating psych. tests writing clinical reports writing progress or process notes max. 250 Workshops seminars training sessions or conferences directly related to marriage family and child counseling max. 250 Client Centered Advocacy CCA Supervision Individual Face-to-Face Supervision Group Total Per Week Signature of Supervisor Please see the FAQ s for instructions on how to report the Conjoint Couples and Families Therapy Incentive hours gained* These categories when combined with credited Personal Psychotherapy shall not exceed 1250 hours of experience. Use a separate log for each supervised work setting and for each status indicated below. Please type or print clearly in ink Name of MFT Trainee/Intern First Last Name of Supervisor Middle Date enrolled in graduate degree program Name of Work Setting Address of Work Setting City State Zip Number and Street Indicate the status of the hours logged Trainee Trainee in Practicum BBS File No if known Post-Degree with Application Pending for Intern Registration B P Code Section 4980. 43 h Registered Intern MFT Intern No* Supervision via video conferencing is not allowed as a trainee Note Child counseling can be logged in any appropriate category as specified by your supervisor YEAR Total Hours WEEK OF Individual Psychotherapy performed by you Couples Families and Children min* 500 hrs. 43 h Registered Intern MFT Intern No* Supervision via video conferencing is not allowed as a trainee Note Child counseling can be logged in any appropriate category as specified by your supervisor YEAR Total Hours WEEK OF Individual Psychotherapy performed by you Couples Families and Children min* 500 hrs. Of the above CFC hours how many actual hours were gained via conjoint couples and family therapy Group Therapy or Counseling max. .

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