DCA BBS 37A-201: Clinical Social Worker In-State Experience Verification

DCA BBS 37A-201 PDF Details

This form is to be completed by the applicant's California supervisor and submitted by the applicant with their Application for Licensure.

Printed editions: 05/2024 (page 1), 10/2024 (page 2).

Before signing: Ensure that this form is complete and correct prior to signing.

Changes: Supervisor must initial any changes.

Weekly Log forms: Do not submit Weekly Log forms unless specifically requested.

Volunteers: If NO (applicant volunteered), applicant must submit a letter from the employer verifying volunteer status.

Signature: Original, scanned or electronic signature required.