Clinical Social Experience Verification – Fill Out and Use This PDF

Clinical Social Experience Verification is a service that provides the necessary documentation to prove you've had relevant work experience in a child and youth care setting.

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Clinical Social Experience Verification PDF Details

This blog post will discuss the importance of clinical social experience verification. It is imperative that all students in a graduate program have at least one year of clinical social work experience before graduation. In order to verify, you need to contact your supervisor and get their permission for this process. Your supervisor can submit a letter on behalf of you with proof from your employer indicating the date range when you were employed there as well as how many hours per week or month they worked during that time frame. This way, any school looking into your background knows that you have had the opportunity to gain valuable skills and learn about different communities in which clients live in order to provide them with quality care.

This information will help you grasp better the details of the clinical social experience verification before you start filling it out.

Question	Answer
Form Name	Clinical Social Experience Verification
Form Length	2 pages
Fillable?	Yes
Fillable fields	44
Avg. time to fill out	9 min 22 sec
Other names	LCSW In-State Experience Verification. LCSW In-State Experience Verification

12

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):					A.


	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?							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

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Clinical Social Experience Verification spaces to complete

Provide the demanded data in the area Name, of, Applicants, Employer Telephone, Address, Number, and, Street City, State, Zip, Code psychotherapy, Yes, Yes, Supervisors, Name Telephone, Email, Address, OPTIONAL SUPERVISOR, INFORMATION License, Type and License, Number

Filling in Clinical Social Experience Verification step 2

The application will request for additional info to effortlessly complete the segment Yes, and If, YES, provide, certificate, number

Finishing Clinical Social Experience Verification stage 3

Through box APPLICANT, NAME, AS, W SUPERVISOR, INFORMATION, continued Yes, Yes, mm, dd, yyyy Total, supervised, weeks, Minimum, overall and Total, hours, in, group, supervision identify the rights and obligations.

Filling in Clinical Social Experience Verification stage 4

End by reading all these fields and preparing them correspondingly: Total, hours, in, group, supervision Average, hours, worked, per, week, Maximum A, BCC and Yes, No

Finishing Clinical Social Experience Verification step 5

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