Form 37A 522 – Fill Out and Use This PDF

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

RESPONSIBILITY STATEMENT FOR SUPERVISORS OF AN

ASSOCIATE CLINICAL SOCIAL WORKER

Title 16, California Code of Regulations (16 CCR) section 1870 requires any qualified licensed mental health professional who assumes responsibility for providing supervision to an individual working toward licensure as a Licensed Clinical Social Worker to complete and sign, under penalty of perjury, the following statement prior to the commencement of supervision, and to provide the Associate with the original.

Associate’s Name: _____________________________________________________________

Last	First	Middle
ASW Number: ____________	Supervisor’s Name: ___________________________________

As the supervisor:

1)I am licensed in California and have been licensed in California or out-of-state for at least two years prior to commencing this supervision. (16 CCR §§ 1870(a) and 1874)

The license I hold in California is:
Licensed Marriage and Family Therapist	License #: _________ Issue Date: ________
Licensed Clinical Social Worker	License #: _________ Issue Date: ________
Licensed Professional Clinical Counselor	License #: _________ Issue Date: ________
Licensed Educational Psychologist (LEP)	License #: __________ Issue Date: ________
*Licensed Psychologist	License #: _________ Issue Date: ________

*Physician certified in psychiatry by the

American Board of Psychiatry and Neurology License #: _________ Issue Date: ________

Are you using time licensed out-of-state to qualify?  Yes  No

2)I have and will maintain a current and active license in good standing and will immediately notify the associate of any disciplinary action, including revocation or suspension, even if stayed, probation terms, inactive license status, or any lapse in licensure, that affects my ability or right to supervise. (16 CCR § 1870(a)(3))

3)I have practiced psychotherapy, provided psychological counseling pursuant to subdivision

(e)of section 4989.14, or provided direct clinical supervision as described in 16 CCR section 1870(a)(4) for at least two (2) years within the last five (5) years immediately preceding this supervision. (16 CCR § 1870(a)(4))

4)I have completed a minimum of fifteen (15) contact hours in supervision training that includes content specified in 16 CCR section 1870(a)(4)) obtained from a state agency or approved continuing education provider.* (16 CCR § 1870(a)(5)(A))

* Psychologists and Physicians board certified in psychiatry are not required to comply with #4.

37A-522 (Revised 01/2020)

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Associate’s Name: _______________________________________________

Supervisor’s Name: ______________________________________________

5)If I am an LEP, I am only supervising the provision of educationally related mental health services that are consistent with the LEP scope of practice. (Business and Professions Code (BPC) § 4996.20(a)(1)(A)

6)I have had sufficient experience, training, and education in the area of clinical supervision to competently supervise associates. (16 CCR § 1870(a)(5))

7)I know and understand the laws and regulations pertaining to both the supervision of associates and the experience required for licensure as a clinical social worker.

(16 CCR § 1870(a)(6))

8)I shall ensure that the extent, kind, and quality of clinical social work performed is consistent with the training and experience of the associate. (16 CCR § 1870(a)(7)(A))

9)I shall review client/patient records, monitor and evaluate assessment and treatment decisions of the associate clinical social worker, and monitor and evaluate the ability of the associate to provide services at the site(s) where he or she will be practicing and to the particular clientele being served, and ensure compliance with all laws and regulations governing the practice of clinical social work. (16 CCR § 1870(a)(7) (B)-(D))

10)I shall develop a supervisory plan as described in 16 CCR section 1870.1. The original signed plan shall be submitted to the board upon the associate’s application for licensure. (16 CCR §§ 1870(a)(8), 1870.1)

11)I agree not to provide supervision to an associate unless the associate is a volunteer or employed by a setting that (1) lawfully and regularly provides clinical social work, mental health counseling, or psychotherapy; and (2) provides oversight to ensure that the associate’s work at the setting meets the experience and supervision requirements set forth in Chapter 14 of the BPC and is within the scope of practice for clinical social work and psychotherapy as defined in BPC section 4996.9.

(BPC § 4996.23.2(d))

12)I shall provide the associate with this original signed form prior to the commencement

of any supervision. (16 CCR § 1870(a)(9))

13)I shall give at least one (1) week's written notice to the associate of my intent not to certify any further hours of experience for such person. If I have not provided such notice, I shall sign for hours of experience obtained in good faith where I actually provided the required supervision. (16 CCR § 1870(a)(10))

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