Clinical Social Experience Verification PDF Details

For individuals seeking licensure as clinical social workers in California, the Clinical Social Work Experience Verification form is a critical component of the application process. Managed by the State of California's Board of Behavioral Sciences, this form serves as a detailed record of an applicant's supervised professional experience in the field. It emphasizes the significance of having a supervisor complete a separate form for each employment position, ensuring that the information provided is both accurate and verifiable. Applicants are required to document comprehensive work details, including the legal and regulatory compliance of the work setting, the oversight provided, and the nature of the clinical social work or psychotherapy performed. The form meticulously outlines the required hours of individual and group supervision, clinical experience, and other professional activities, establishing a minimum threshold for various types of engagements. Additionally, it addresses the necessity of adhering to ethical standards, highlighting that any misleading or omitted information could jeopardize the licensure application. This form not only underscores the state's commitment to maintaining high standards in the clinical social work profession but also ensures that applicants are adequately prepared for their licensure examination and future career in social work.

QuestionAnswer
Form NameClinical Social Experience Verification
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names LCSW In-State Experience Verification. LCSW In-State Experience Verification

Form Preview Example

STATE OF CALIFORNIA - BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY

Gavin Newsom, Governor

Board of Behavioral Sciences

1625 North Market Blvd., Suite S200, Sacramento, CA 95834

Telephone: (916) 574-7830

www.bbs.ca.gov

CLINICAL SOCIAL WORKER

IN-STATE EXPERIENCE VERIFICATION

Have your supervisor complete this form as described below:

oUse a separate form for each supervisor and employer

oMake sure this form is complete and correct prior to signing

oProvide an original or electronic signature and have the signer initial any changes

oSubmit with your Application for Licensure

APPLICANT NAME: ___________________________________

 

ASW Number: ___________

 

 

APPLICANT’S EMPLOYER INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Applicant’s Employer:

 

 

 

 

 

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

Number and Street

 

 

 

City

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

1. Did this setting lawfully and regularly provide clinical social work, mental health counseling or

 

psychotherapy?

Yes

No

 

 

 

 

 

 

 

 

 

 

2. Did this setting provide oversight to ensure the ASW’s work met the experience and supervision

 

requirements and was within the scope of practice?

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPERVISOR INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supervisor’s Name

 

 

 

Telephone

 

 

 

 

Email Address (OPTIONAL)

 

 

 

 

 

 

 

 

 

 

 

 

 

License Type

 

 

License Number

 

 

State

 

 

Date First Licensed*

 

 

 

 

 

 

If a physician, were you certified in Psychiatry by the American Board of Psychiatry and Neurology during

 

the entire period of supervision?

 

Yes

No

N/A

 

 

 

 

 

 

 

 

If YES, provide certificate number:_________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*If licensed in California for less than two years on the first date of experience claimed, attach out-of-state license information

37A-201 (Revised 01/2022)

1 of 2

APPLICANT NAME: __________________________________________ ASW#: _______________

SUPERVISOR INFORMATION (continued)

 

Were you (the supervisor) employed by the supervisee’s employer?

Yes

No

 

 

 

 

 

If NO, did you and the supervisee’s employer sign a written agreement pertaining to oversight of

 

 

the supervisee?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

EXPERIENCE INFORMATION:

Dates of experience: From ____________

to ____________

 

 

 

 

(mm/dd/yyyy)

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

1.

Total supervised weeks (Minimum 104 overall):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Total hours in individual or triadic supervision (Minimum 52 overall):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Total hours in group supervision:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Average hours worked per week (Maximum 40):

 

 

 

 

 

 

 

 

 

 

 

5. Total hours of clinical psychosocial diagnosis, assessment, and treatment, including

A.

 

 

 

 

individual or group psychotherapy / counseling (Minimum 2,000 overall):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Of the above hours, how many were gained performing face-to-face individual or

 

 

 

 

 

group psychotherapy/counseling

(Minimum 750 overall):

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Total hours of client-centered advocacy, consultation, evaluation, research,

 

B.

 

 

 

 

workshops, seminars, training sessions or conferences and direct supervisor contact*

 

 

 

 

 

(Maximum 1,000 overall):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Total hours of experience (Minimum 3,000 overall):

(A + B = C)

C.

 

 

 

 

 

 

 

 

 

 

9.

Was one additional hour of face-to-face individual or triadic supervision OR two

 

 

Yes

 

 

additional hours of face-to-face group supervision provided for every week in which more

 

No

 

 

than 10 hours of direct clinical counseling was performed?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*A maximum of six (6) hours of direct supervisor contact per week may be counted toward the 1,000 hours.

NOTE: Knowingly providing false information or omitting pertinent information may be grounds for denial of the application. The Board may take disciplinary action on a licensee who helps an applicant obtain a license by fraud, deceit or misrepresentation. All information on this form is subject to verification.

Signature of Supervisor: _____________________________________ Date: ______________

ORIGINAL OR ELECTRONIC SIGNATURE REQUIRED

37A-201 (Revised 01/2022)

2 of 2

How to Edit Clinical Social Experience Verification Online for Free

Our PDF editor will make creating forms convenient. It is rather effortless change the [FORMNAME] form. Adhere to these steps to be able to accomplish this:

Step 1: Step one is to pick the orange "Get Form Now" button.

Step 2: After you enter the Clinical Social Experience Verification editing page, there'll be each of the actions it is possible to undertake regarding your form at the upper menu.

Complete the Clinical Social Experience Verification PDF by typing in the data required for every section.

Clinical Social Experience Verification spaces to complete

Provide the demanded data in the area Address, Number and Street, City, State Zip Code, Did this setting lawfully and, psychotherapy, Yes, Did this setting provide, requirements and was within the, Yes, Supervisors Name, Telephone, Email Address OPTIONAL, SUPERVISOR INFORMATION, and License Type.

Filling in Clinical Social Experience Verification step 2

The application will request for additional info to effortlessly complete the segment APPLICANT NAME ASW, SUPERVISOR INFORMATION continued, Were you the supervisor employed, Yes, If NO did you and the supervisees, Yes, EXPERIENCE INFORMATION Dates of, mmddyyyy, Total supervised weeks Minimum, Total hours in individual or, Total hours in group supervision, Average hours worked per week, and Total hours of clinical.

Finishing Clinical Social Experience Verification stage 3

Through box individual or group psychotherapy, Of the above hours how many were, group psychotherapycounseling, Total hours of clientcentered, workshops seminars training, Total hours of experience Minimum, A B C C, Was one additional hour of, Yes, A maximum of six hours of direct, and NOTE Knowingly providing false, identify the rights and obligations.

Filling in Clinical Social Experience Verification stage 4

End by reading all these fields and preparing them correspondingly: Signature of Supervisor Date, and A Revised.

Finishing Clinical Social Experience Verification step 5

Step 3: Choose "Done". It's now possible to export your PDF file.

Step 4: Ensure that you stay clear of possible future problems by getting at least 2 duplicates of your document.

Watch Clinical Social Experience Verification Video Instruction

Clinical Social Experience Verification isn’t the one you’re looking for?

Related Documents

  • Identity Verification Form

    "... Identity verification form on request from psnenergy. This form is required to verify an individual's identity in connection to establishing or maintaining a utility account with the company. Section ii The undersigned state and declare ..."

  • Edd Ideninty Verification

    "... This notice has been sent to you because the employment department ed cannot verify your identity. The information that you submitted when filing your unemployment insurance claim was not compatible with the information that is ..."

  • Ftc Identity Theft Affidavit

    "... Leave blank until someone has a legitimate business reason to receive this form. For example, when you file your report to the police station. To correct your credit card report. Skip 10 ..."

  • Ibm Employment Verification

    "... Employment verification and authorization form. Fax the completed form to 508 3577220, or mail it to ibm employment center at tn 5411 Page Road Durham NC 27703 serial contact. Authorize ibm t release information relat ..."

Please rate Clinical Social Experience Verification

1 Votes

Related Resources

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .