830 TTY: (800) 326-2297 www.bbs.ca.gov WEEKLY SUMMARY OF EXPERIENCE HOURS FOR PROFESSIONAL CLINICAL COUNSELOR INTERNS THIS FORM SHALL BE COMPLETED PURSUANT TO TITLE 16, CALIFORNIA CODE OF REGULATIONS SECTION 1820(e) Use a separate log for each supervised work setting. (Please type or print clearly in ink) Name of PCC Intern: First Last Middle Name of Supervisor: BBS File No (if known) Name of Work Setting: Address of Work Setting: Indicate the status of the hours logged: Registered PC.
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How to fill out the CA BBS 37A-645 online
Filling out the CA BBS 37A-645 form correctly is essential for professional clinical counselor interns in California to log their weekly experience hours. This guide provides clear, step-by-step instructions on how to complete the form online, ensuring that you meet the necessary requirements.
Follow the steps to successfully complete the CA BBS 37A-645 form.
- Press the ‘Get Form’ button to access the CA BBS 37A-645 form in your editing interface.
- Start by entering your name as the PCC intern in the designated fields, including your first, last, and middle name.
- If applicable, input the name of your supervisor and their BBS file number.
- Fill in the name and address of the work setting where you are gaining experience, along with the city, state, and zip code.
- Indicate your current status by selecting whether you are a registered PCC intern or post-degree with an application pending for intern. Make sure to include your PCC intern number if you are registered.
- Specify whether the work setting is a hospital or community mental health setting by selecting 'Yes' or 'No.'
- Record the year and the week of the experience hours you are logging.
- In the designated sections, log the hours for individual psychotherapy, group therapy, telephone counseling, and other relevant activities, ensuring you adhere to the maximum limits specified for each category.
- Sum the total hours logged for the week and enter that in the total section.
- Ensure your supervisor signs the form in the designated area to validate the logged hours.
- Once all sections are completed, you can save the changes, download the form for your records, print it, or share it as needed.
Begin completing your CA BBS 37A-645 form online today.
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