Washington Supervised Experience Verification Forms: DOH 670-027, 670-011, and 670-005

One Form Per Supervisor, Per Setting

Every Washington experience-verification form runs the same way. The candidate completes the first section with their own details, then forwards the form to the supervisor. The supervisor fills in the hour lines, the dates supervised, and a signed certification. Each form says so directly: DOH 670-027 tells the counseling applicant to "fill out Section one and forward to the supervisor for completion," and DOH 670-011 and DOH 670-005 print the same instruction in nearly the same words for social work and marriage and family therapy.

All three forms carry the same instruction on supervisors and settings: "use a separate form for each supervisor verifying your postgraduate supervision and professional experience for each practice setting" (DOH 670-027, July 2020; DOH 670-011, May 2023; DOH 670-005, May 2023). The counseling and MFT forms repeat it at the foot of the page: "please provide a separate form for each supervisor." The copy of DOH 670-027 bundled in the LMHC application packet (DOH 670-036) carries a July 2025 footer; the standalone form DOH links is dated July 2020. A candidate with two supervisors, or one supervisor across two practice settings, needs two signed forms, not one.

LMHCA to LMHC: DOH 670-027 and DOH 670-128

The primary form is DOH 670-027, "Verification of Mental Health Counselor Supervised Postgraduate Experience" (July 2020), addressed to Mental Health Credentialing. After the applicant's section and the supervisor's contact details, the form prints a "Months of Supervision" date range, From and To, then three hour lines and a total: A, "Immediate Supervision, means a meeting with an approved supervisor, involving one supervisor and no more than two licensing consultants" (at least 100 required); B, "Direct Counseling, with individual couples, families, or groups" (at least 1,200 required); C, "All other hours, hours not listed in section A or B" (unlimited); and D, the total of A plus B plus C, printed as "Total of 3,000." The form's own wording, "licensing consultants," is a misprint of the rule's "licensure candidates" (WAC 246-809-210(6)).

The supervisor's certification reads, "I certify that the above information is, to the best of my knowledge, accurate and complete. I understand that the Department may request additional information, if it is needed, to evaluate the application of the individual named on this document. I also attest I meet or exceed the educational and supervision requirements to be an approved supervisor," followed by a signature and date line (DOH 670-027).

A second form, DOH 670-128, "Mental Health Counselor Associate Supervision and Experience Verification" (December 2010), carries the same hour lines without the lettered boxes: immediate supervision (100 required), direct counseling (1,200 required), all other supervised hours, and a total (3,000 required), with the identical certification and a supervised-dates field. DOH links DOH 670-128 from the associate section of its counseling licensing page and packages DOH 670-027 in the LMHC application packet; either way, one copy per supervisor.

LSWAIC to LICSW: DOH 670-011

DOH 670-011 (May 2023) is two pages under one number. Page one, "Social Worker Supervised Postgraduate Experience Requirements," restates the hour totals for each social work path: for a licensed advanced social worker, 3,000 hours with 800 in direct client contact and 90 in direct supervision (40 one-to-one, 50 one-to-one or group); for a licensed independent clinical social worker, 3,000 hours over a minimum of two years with 1,000 in direct client contact and 100 in direct supervision (70 with an LICSW, 60 one-to-one). Page two, "Verification of Social Worker Supervised Postgraduate Experience," is what the supervisor signs.

The form has a type checkbox, "Licensed Advanced Social Worker" or "Licensed Independent Clinical Social Worker," then the supervisor fills in a "Dates of Supervision" range and four hour boxes: A, "number of hours of direct client contact"; B, "number of hours of one-on-one supervision"; C, "number of hours of group supervision"; D, "number of other hours"; and E, the total, "A + B + C + D = E." Page two warns, "experience gained through inappropriate supervision will not count toward the applicant's supervised postgraduate experience requirement," and that "the supervisor must be licensed and legally able to practice in the location where supervision hours are being earned" (DOH 670-011).

The certification on page two drops the "meet or exceed" language the counseling and MFT forms use: "I certify that the above information is, to the best of my knowledge, accurate and complete. I understand the department may request additional information, if it is needed, to evaluate the application of the individual named on this document." A supervisor can submit the form by mail or email it as a PDF attachment to SWapplication@doh.wa.gov, per DOH's social worker licensing-information page.

LMFTA to LMFT: DOH 670-005

DOH 670-005, "Marriage and Family Therapy Supervision and Experience Verification" (May 2023), prints all of its hour boxes on page two, under "Supervised Postgraduate Experience." Box A is "diagnosing and treating couples and families" (at least 500 required); box B is direct client contact not already counted in A; boxes A plus B must equal the figure in line "1," 1,000 hours. Box C is "number of hours of group supervision"; box D is one-on-one supervision (100 required); boxes C plus D must equal line "2," 200 hours. Line "3" catches all other hours not listed above, and the total, lines 1 plus 2 plus 3, must reach 3,000 hours. The form also prints a "Months of Supervision" From and To date range; the hour totals behind each box are in Washington LMFT requirements.

The form still describes an approved supervisor as "a licensed marriage and family therapist with at least five years' clinical experience or an equally qualified mental health practitioner," and describes the supervision itself as "face-to-face." The rule sets the supervisor's clinical experience at two years, not five (WAC 246-809-130(3)(b)(i)), and permits supervision "face-to-face or virtual" (WAC 246-809-110(4), (6)). The form has not caught up to either change.

The certification matches the counseling form: "I certify that the above information is, to the best of my knowledge accurate and complete. I understand that the Department may request additional information, if it is needed, to evaluate the application of the individual named on this document. I also attest I meet or exceed the educational and supervision requirements to be an approved supervisor," with a signature and date line, and the same instruction, "please provide a separate form for each supervisor" (DOH 670-005).

The Three Approved Supervisor Declarations

Separate from the hour-verification forms, each track has an "Approved Supervisor Declaration" the supervisor completes and hands to the candidate before supervision starts: DOH 670-130 for a counseling candidate, DOH 670-091 for a social work candidate, and DOH 670-099 for an MFT candidate, all revised March 2025. Each declaration restates the license requirement (without restrictions, in good standing for at least two years) and has the supervisor attest to a minimum of 15 clock hours of training in clinical supervision, 25 hours of experience in supervision of clinical practice, and thorough knowledge of the candidate's practice setting, recordkeeping, financial management, ethics of clinical practice, and a backup plan for coverage. Each also tells the supervisor they must not be a blood or legal relative or cohabitant of the candidate, the candidate's peer, or someone who has acted as the candidate's therapist within the last two years. DOH 670-091 adds one more line for social work supervisors: "two years of clinical experience post license."

DOH 670-099 alone carries a substitution: "an American Association for Marriage and Family Therapy (AAMFT) approved supervisor is considered to have met the qualifications above. Please submit proof of AAMFT approval." Each declaration closes with the supervisor naming their license type, license number, and state, and attesting they have read and met the requirements of the matching rule, then a signature and date.

What to Record From Day One

These forms are hard to fill in from memory months later. Before the forms exist, an associate needs the raw material every one of them asks for: the exact start and end date under each supervisor, the practice setting where each block of hours was earned, and hours sorted the way the applicable form sorts them, immediate supervision and direct counseling for the counseling forms, direct client contact and one-on-one and group supervision for the social work form, couples-and-families contact, other direct contact, group, and one-on-one supervision for the MFT form. A change of supervisor or setting midway through the associate license means a new form, so the record needs to mark exactly where one supervisor's hours end and the next one's begin.

This is bookkeeping advice about the forms themselves, not a claim about any particular software. The orientation for the whole path, before any of these forms come into play, is how to become a therapist in Washington State, and what happens to CE and renewal after the license itself is issued is covered in Washington associate license renewal and CE.

Every Washington Verification Form at a Glance

Every row above needs a fresh copy for each supervisor and each practice setting; none of them are one-and-done across a whole associate license.

Common Mistakes on the Washington Verification Forms

Related Washington Guides

FAQ: Washington Supervised Experience Verification Forms