Bbs responsibility statement 37a 523 2025

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  1. Click ‘Get Form’ to open the bbs responsibility statement 37a 523 in the editor.
  2. Begin by entering the name of the MFT Trainee/Intern in the designated fields for Last and First names.
  3. Next, input your name as the Qualified Supervisor, including your middle name if applicable.
  4. Provide your daytime telephone number to ensure easy communication.
  5. Carefully review each statement under the supervisor's responsibilities. Confirm your qualifications and experience by checking the appropriate boxes and filling in any required license details.
  6. Sign and date the form at the bottom, ensuring that all information is accurate and complete before submission.
  7. Once completed, download or share the signed document directly from our platform for free, ensuring it reaches the necessary parties promptly.

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Mental health professionals authorized to supervise Associate Clinical Social Workers, under California law, must maintain a current and valid license, for the following: Licensed Marriage and Family Therapist (LMFT) Licensed Clinical Social Worker (LCSW) Licensed Professional Clinical Counselor (LPCC)
One unit of supervision equals one hour of individual or triadic supervision or two hours of group supervision Each Week: One unit of supervision is required in each work setting Weekly Ratio: One unit of supervision is required for every five hours of direct clinical counseling provided in a single week in each
(d)(b) A supervisor shall give at least one (1) weeks prior written notice to an associate supervisee of the supervisors intent not to sign for any further hours of experience for such person.
THE DELEGATED SUPERVISOR(S): Must be a licensed psychologist or other licensed mental health professional as listed in section 1387(c)(1); for registered psychological associate, delegated supervisor(s) must be a licensed psychologist pursuant to section 1391.5.
The Education Law defines qualified supervisors as licensed clinical social workers, licensed psychologists and psychiatrists; no other professions are allowed to supervise. The supervisor must have been licensed before starting to supervise you.

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Title 16, California Code of Regulations (16 CCR) section 1870 requires any qualified licensed mental health professional who assumes responsibility for providing supervision to an individual working toward licensure as a Licensed Clinical Social Worker to complete and sign, under penalty of perjury, the following
The Supervision Agreement replaces the Supervisor Responsibility Statement (formerly required for LCSW, LPCC and LMFT) and Supervisory Plan (formerly required for LCSW and LPCC). New requirements apply only to NEW supervisory relationships established on or after January 1, 2022.

bbs supervision agreement form