Form 37A-201 at a glance
What it is: DCA BBS 37A-201 is the Clinical Social Worker In-State Experience Verification.
Who signs: Sign on Supervisor Signature and enter the Date: ORIGINAL, SCANNED OR ELECTRONIC SIGNATURE REQUIRED.
This form is to be completed by the applicant's California supervisor and submitted by the applicant with their Application for Licensure.
A filled-in Form 37A-201 example: a supervisor verifies a year of experience
How to fill out Form 37A-201, box by box
Applicant name and dates of experience
Enter the applicant's name (Last, First, Middle), the Associate Number after ASW, and the Dates of experience (mm/dd/yyyy): From and To.
Supervisor information
Under SUPERVISOR INFORMATION, enter the Supervisor's Name, Email Address (if supervisor has one), Business Phone, License Type, License Number and Date First Licensed*. For Date First Licensed*: if licensed in California for less than two years on the first date of experience claimed by the applicant, attach your out-of-state license information.
Physicians: Were you certified in Psychiatry
Physicians: mark N/A, No or Yes to Were you certified in Psychiatry by the American Board of Psychiatry and Neurology during the entire period of supervision? If Yes, enter Date Certified and Certification Number.
Were you (the supervisor) employed by the supervisee's employer?
Mark Yes or No to Were you (the supervisor) employed by the supervisee's employer?
If NO, mark Yes or No to did you and the supervisee's employer sign a written agreement pertaining to oversight of the supervisee? If YES, applicant must submit a copy of this agreement.
Applicant's employer information
Under APPLICANT'S EMPLOYER INFORMATION, enter the Name of Applicant's Employer, Business Phone, and Address: Number and Street, City, State and Zip Code.
Private practice and pay
Mark Yes or No to 1. Was this experience gained in a private practice or professional corporation setting?
Mark Yes or No to 2. Was the applicant receiving pay? If YES, applicant must submit a copy of their W-2 statement for each year experience is claimed (if a W-2 has not yet been issued for this year, submit a copy of the current paystub).
If NO (applicant volunteered), applicant must submit a letter from the employer verifying volunteer status.
Experience information
Under EXPERIENCE INFORMATION, enter the Dates of Experience (mm/dd/yyyy): From and To, and how many supervised weeks of experience are being claimed.
Hours of Experience
Under 3. Hours of Experience, enter Logged Hours for a. Total hours of clinical psychosocial diagnosis, assessment, and treatment, including individual or group psychotherapy or counseling, and of the above hours in box 3a, how many were gained performing face-to-face individual or group psychotherapy provided in the context of clinical social work services.
Enter Logged Hours for b. Total hours of client-centered advocacy, consultation, evaluation, research, workshops, seminars, training sessions or conferences, direct supervisor contact, and of the above hours in box 3b, how many were Face-to-Face Supervision: Individual or Triadic Supervision and Group Supervision.
Supervisor Signature
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.
Sign on Supervisor Signature and enter the Date: ORIGINAL, SCANNED OR ELECTRONIC SIGNATURE REQUIRED.
More rules for Form 37A-201
Use a separate form for each supervisor and employment setting.
Ensure that this form is complete and correct prior to signing. Supervisor must initial any changes.
Do not submit Weekly Log forms unless specifically requested.
Sources
[1] DCA BBS 37A-201, Clinical Social Worker In-State Experience Verification, California Board of Behavioral Sciences (the Official source link on this page).
