BBS LPCC in-state experience verification form 37A-644 - bbs ca 2026

1. Click ‘Get Form’ to open the BBS LPCC in-state experience verification form 37A-644 in the editor.
2. Begin by entering your personal information in the 'APPLICANT NAME' section, including your last name, first name, middle name, and intern number.
3. Next, fill out the 'SUPERVISOR INFORMATION' section. Provide your supervisor's name, license type, business phone number, license number, state, and date first licensed.
4. Indicate whether your supervisor was certified in Psychiatry and if they were employed by your employer. If not employed by the supervisee’s employer, attach a letter of agreement.
5. Complete the 'APPLICANT’S EMPLOYER INFORMATION' section with your employer's name, address, and business phone number.
6. Answer the questions regarding your experience settings by selecting 'Yes' or 'No' for each item listed.
7. In the 'EXPERIENCE INFORMATION' section, provide dates of experience claimed and specify how many weeks of supervised experience you are claiming.
8. Log hours of experience under various categories as specified. Ensure that you adhere to maximum limits for each category.
9. Finally, have your supervisor sign and date the form to validate it before submission.

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