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.

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)

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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)

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How to Edit Clinical Social Experience Verification Online for Free

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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.

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