Verification of Clinical Experience - DH-MQA 1181 Revised 5/2025

Sep 21, 2026

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Verification of Clinical Experience form for applicants seeking Florida intern registration and supervised clinical experience credit. The form requires supervisor completion, including supervisor identity and contact details, license information for out-of-state supervisors, and a structured log of supervised clinical experience dates and hours. It collects confirmation that supervision meets Rule 64B4-2 requirements, including supervision frequency and psychotherapy hours, plus a supervisor affirmation with signature and date.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages1

Reading Time3 min

AccessFree to download

Verification requirements

Supervisor information

Supervised clinical experience

Supervisor statement

Submit form with application, email [to](to MQA.491@flhealth.gov)[ ](to MQA.491@flhealth.gov)[MQA.491@flhealth.gov](to MQA.491@flhealth.gov), or mail to: Board of Clinical Social Work, Marriage and Family Therapy, and Mental Health Counseling 4052 Bald Cypress Way Bin C‐08 Tallahassee, FL 32399‐3258 Verification of Clinical Experience Form must be completed by the supervisor. Applicant Name: Florida Intern Registration Number/Other State License Number: Select profession: Clinical Social Work Marriage & Family Therapy Mental Health Counseling 1. SUPERVISOR INFORMATION Supervisor Name: Email Address: | License Type | State | License Number | | --- | --- | --- | | | | | Supervisors licensed outside of Florida must provide a license verification. 2. SUPERVISED CLINICAL EXPERIENCE I have read and understand Rule 64B4-2, Florida Administrative Code (F.A.C. ), which states, in part: An intern shall be credited for the time of supervision required by section (s. ) 491 .005, Florida Statutes, if the intern: a) Received at least 100 hours of supervision in no less than 100 weeks; and b) Provided at least 1,500 hours of face-to-face psychotherapy with clients; and c) Received at least one hour of supervision every two weeks A. Dates of supervision: Start Date: End Date: MM/DD/YYYY Provide specific date-MM/DD/YYYY B. The applicant received hours of supervision, with at least one hour of supervision every two weeks. C. The applicant provided psychotherapy face-to-face with clients for a total of hours. Select one of the following: I intend to provide supervision until the registered intern is fully licensed pursuant to s. 491.0045(3), F.A.C. If this changes, I will notify the board office of the date supervision ended. I am no longer providing this registered intern with supervision as of: MM/DD/YYYY 3. SUPERVISOR STATEMENT As the qualified supervisor of this intern, I affirmatively state that I have complied with all the duties of a qualified supervisor as established in Rule 64B4-2 .0025, F.A.C. , during the course of the supervision of this applicant. Supervisor Signature: Date: MM/DD/YYYY DH-MQA 1181, Revised 5/2025, Rule 64B4-3 .0015 Page 1 of 1

FAQs

Who must complete the Verification of Clinical Experience form?

The form must be completed by the supervisor. The applicant provides required personal and experience selections, but the supervisor completes the supervisor sections and affirmation.

What supervision standards must the intern meet under Rule 64B4-2?

The intern must receive at least 100 hours of supervision in no less than 100 weeks, receive at least one hour of supervision every two weeks, and provide at least 1,500 hours of face-to-face psychotherapy with clients.

What information does the form collect about supervised clinical experience?

It collects supervision start and end dates, the total hours of supervision received with the required frequency, and the total hours of face-to-face psychotherapy provided to clients, plus the supervision intent or termination date.

What is required in the supervisor statement section?

The supervisor must affirm compliance with qualified supervisor duties under Rule 64B4-2. The section includes the supervisor signature and date.

Sep 21, 2026

Upload by Ben