Fillable BBS APPLICATION FOR LICENSURE LICENSED CLINICAL SOCIAL WORKER (California)

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BBS APPLICATION FOR LICENSURE LICENSED CLINICAL SOCIAL WORKER (California)

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BBS
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
LICENSED CLINICAL SOCIAL WORKER
IN-STATE
APPLICATION FOR LICENSURE
For Applicants who hold a California Associate Registration*
Dear Applicant:
Thank you for your interest in becoming a California Licensed Clinical Social
Worker (LCSW). Included in this packet are the following forms and documents:
1. Application Instructions
2. Important Information for Applicants
3. LCSW Application for Licensure
4. In-State Experience Verification
BOARD OF BEHAVIORAL SCIENCES
*This application may also be used by applicants with an Out-of-State
degree who have gained experience hours in California. You may
have coursework to complete - please refer to the notice sent upon
approval of your Associate application. If you have any Out-of-State
experience, please use an Out-of-State Experience Verification form
.
Do not use this application if you are licensed at the highest level for
independent practice in another state. Use the Out-of-State
Application for Licensure instead.
)!(
BBS
Board
of
Behavioral
Sciences
LICENSED CLINICAL
SOCIAL WORKER
In-State Applicant
Application Instructions
Read Carefully Before Completing Your Application
Submit completed application to: Board of Behavioral Sciences
1625 North Market Blvd., Suite S200
Sacramento, CA 95834
EXPEDITED REVIEW
The Board is required to expedite the licensure process for the following applicants:
• Honorably discharged veterans of the U.S. Armed Forces pursuant to Business and
Professions Code (BPC) section 115.4. Download the request form from the Board’s
website and include it ON TOP OF your application.
• Spouses/Partners of persons on active duty military pursuant to BPC section 115.5.
Download the request form from the Board’s website and include it ON TOP OF your
application.
• Refugees / Asylees / Special Immigrant Status Holders ("SI" or "SQ") pursuant to
BPC section 135.4. Download the request form from the Board’s website and include it
ON TOP OF your application.
RECEIPT OF APPLICATION
If you would like to know whether the Board has received your application, you will need to
mail your application using a method that includes tracking. You can also check with your
bank to see if your check or money order has been cashed by the Board.
Carefully read all instructions to ensure an accurate and complete application
package and that all required original documents are furnished to the Board.
All items are mandatory unless otherwise indicated.
Any omission may result in your application being deficient or delayed.
37A-532 (Revised 01/2021) 1
A. APPLICATION
Instructions Document(s) Required
• Complete all sections of the Application for Licensure in ink.
• The application must have your original signature.
• You must use your legal name. Your “legal name” is the name
established legally by your birth certificate, marriage or domestic
partnership certificate, or divorce decree (for example).
• Name Change: If you have registered with the Board previously
and have changed your legal name without notifying the Board,
submit a Notification of Name Change form with your application
packet along with the required documentation.
• Email Address: The Board strongly recommends submission of
your email address to facilitate communication.
Completed and signed
Application for
Licensure
B. FEE
Instructions Document(s) Required
Attach a $250.00 check or money order made payable to the
Behavioral Sciences Fund. This application fee is an earned fee for
evaluation of your application and is NOT REFUNDABLE.
$250 check or money
order payable to
Behavioral Sciences
Fund
C. ADDITIONAL COURSEWORK
Instructions Document(s) Required
Provide proof of completion of the following required courses with your
application, unless the training is identified on transcripts previously
submitted for ASW registration. See next page for course list.
Proof of course
completion (unless
previously submitted)
37A-532 (Revised 01/2021) 2
C. ADDITIONAL COURSEWORK (continued)
Course
Required of:
Length
1. Child Abuse Assessment
and Reporting in California
All applicants
7 hours
Professions Code
Section 28
• Course must be based
2. Human Sexuality
All applicants
10 hours
3. Alcoholism and Chemical
Substance Abuse &
Dependency
All applicants
15 hours
4. Aging, Long Term Care and
Elder/Dependent Adult
Abuse
Applicants who
entered a MSW
program after
1/1/2004
10 hours
Spousal/Partner Abuse
Assessment, Detection, and
Intervention
All applicants
EXCEPT for
those who
entered a MSW
program prior to
01/01/1995
• No specific number
of hours for those
who entered a MSW
program prior to
12/31/03, but must
be of sufficient length
to cover the topics of
assessment,
detection and
intervention
• 15 hours for those
who entered a MSW
program after
1/1/2004
BPC section
4996.2(f)
D. SUICIDE RISK ASSESSMENT AND INTERVENTION TRAINING
Instructions Document(s) Required
Six (6) hours of coursework or applied experience in Suicide Risk
Assessment and Intervention is required. If this content was included
within your supervised experience, and you can obtain a written
certification from the program’s director of training, or from your
primary supervisor stating that the training was included within your
supervised experience, it may be accepted in lieu of a course.
(continued on next page)
Proof of completion
37A-532 (Revised 01/2021) 3
D. SUICIDE RISK ASSESSMENT & INTERVENTION COURSEWORK (continued)
Instructions Document(s) Required
If this content was included within your qualifying degree program, you
will need to obtain a written certification from the registrar or training
director of your school or program stating that this coursework was
included within the curriculum required for graduation, or within the
coursework that was completed by you.
Otherwise, this requirement may be met by taking a six-hour course
from a school that holds a regional or national institutional
accreditation recognized by the U.S. Department of Education, a
school approved by the California Bureau for Private Postsecondary
Education, or an acceptable continuing education provider.
E. SUPERVISED EXPERIENCE
Instructions Document(s) Required
Supervised post-degree work experience must total at least two years
(104 weeks) and 3,000 hours. The supervised experience must have
been obtained within the six (6) years immediately preceding the date
on which your Application for Licensure is received by the Board.
EXPERIENCE VERIFICATION: Each supervisor of your experience
hours must verify your experience on an Experience Verification form.
WRITTEN AGREEMENT: If your employer did not employ your
supervisor, attach a copy of the signed written oversight agreement as
required by law. A sample is available on the Board’s website.
W-2s: If you were employed, you must submit a copy of your W-2 for
each year you are claiming experience and for each employer. If your
W-2 is not available, you may submit a copy of your “Wage and
Income Transcript” from the Internal Revenue Service. If a W-2 is not
available for the current year, attach a copy of a current pay stub. If your
W-2 statement does not match the name of your employer as stated on
your verification of experience, an explanation is required. If you are
submitting a 1099 form, an explanation is required.
VOLUNTEER LETTER: If you volunteered while gaining hours, attach
a copy of the letter from your employer verifying your voluntary status
on your employer’s letterhead. The letter must state the time frame
(date range) during which you volunteered. See sample letter.
SUPERVISOR RESPONSIBILITY STATEMENT: Submit the original
Supervisor Responsibility Statement signed by each supervisor.
SUPERVISORY PLAN: Submit the initial original Supervisory Plan
signed by each initial supervisor.
Original Experience
Verification form(s)
Original Signed/dated
letter(s) of agreement
(if applicable)
Copies of W-2
Form(s)/Check Stub
for Current Year (if
applicable)
Original Volunteer
Letter(s) (if applicable)
Original Supervisor
Responsibility
Statement(s)
Original Supervisory
Plan(s)
37A-532 (Revised 01/2021) 4
F. EXAMINATIONS
Instructions Document(s) Required
You must pass the California Law and Ethics Examination (if you
have not already) and the Association of Social Work Boards (ASWB)
Clinical Examination. You will be eligible to take your initial exam after
your Application for Licensure has been approved. You will be
provided with information on how to register at that time. Additional
information is provided under the Exams tab on the Board’s website.
None at this time
G. APPLY FOR INITIAL LICENSE ISSUANCE
Instructions Document(s) Required
Upon meeting all requirements for licensure, you must submit a
Request for Initial License Issuance and fee. Do not submit at this
time – it will be rejected.
AFTER you pass BOTH
exams, submit a Request
for Initial License
Issuance and fee
37A-532 (Revised 01/2021) 5
BBS
Board
of
Behavioral
Sciences
Important Information for
LICENSED CLINICAL
SOCIAL WORKER
APPLICANTS
1. ABANDONMENT OF LICENSURE APPLICATION
An application shall be deemed abandoned in any of the circumstances described below.
Abandonment could have major consequences, including the loss of any experience hours
more than six (6) years old at the time of application. Per Title 16, California Code of
Regulations Section 1806, an application shall be deemed abandoned when:
• You do not submit evidence that you have cleared the deficiencies specified in the
deficiency letter within one (1) year from the date of the initial deficiency letter.
• You fail to sit for examination within one (1) year after being notified of eligibility.
• You fail to pay the initial license fee within one (1) year after notification by the board of
successful completion of examination requirements.
To re-open an abandoned application, you must submit a new application, fee and all
required documentation, as well as meet all current licensure requirements in effect at the
time the new application is submitted.
2. EXAMINATION
Once the Board evaluates your application, you will receive one of the following:
• A notice describing any deficiencies in your application OR
• A notice of eligibility to take the examination.
o You will not be eligible to take the National Association of Social Work Boards
(ASWB) Clinical Examination until you have passed the LCSW California Law and
Ethics Exam. You will receive information on registering for each exam upon
approval of your application.
The examinations contain objective multiple-choice questions and are offered at locations
throughout California and in other states. Upon receipt of your notice of eligibility, it is your
responsibility to contact the testing administrator to schedule your examination. Further
information about the examination process is provided under the Exams tab on the Board’s
website.
37A-317 (Revised 01/2020) 1
I
3. REQUEST FOR TESTING ACCOMMODATION – DISABILITY OR ENGLISH AS A
SECOND LANGUAGE
Refer to the Board’s website for information on how to apply for testing accommodations.
4. NONDISCRIMINATION AND ADA COORDINATOR
The Executive Officer of the Board has been designated to coordinate and carry out the
Board’s compliance with the nondiscrimination requirements of Title II of the Americans with
Disabilities Act (ADA). Information concerning the provisions of the ADA, and the rights
provided thereunder, are available from the ADA coordinator.
5. PUBLIC ADDRESS and CHANGE OF ADDRESS
The address you enter on any Board form is public information and will be placed on the
Internet pursuant to Business and Professions Code section 27. If you do not want your
home or work address available to the public, use an alternate mailing address, such as a
post office box. California law requires all persons regulated by the Board to notify the Board
in writing within 30 days of any change of address.
6. STATUTES AND REGULATIONS
To obtain a copy of the Board’s Statutes and Regulations, please access it from the Board’s
website.
7. MANDATORY REPORTER
Under California law each person licensed by the Board is a “mandated reporter” for both
child, elder and/or dependent adult abuse or neglect. California Penal Code section 11166
and Welfare and Institutions Code section 15630 require that all mandated reporters make a
report to an agency specified [generally law enforcement, state, and/or county adult
protective services agencies, etc… ] in Penal Code section 11165.9 and Welfare and
Institutions Code section 15630(b)(1) whenever the mandated reporter, in their professional
capacity or within the scope of their employment, has knowledge of or observes a child,
elder and/or dependent adult whom the mandated reporter knows or reasonably suspects
has been the victim of child abuse or elder abuse or neglect.
The mandated reporter must make a report of such abuse or neglect immediately, or as
soon as practically possible, in the manner specified in Penal Code section 11166 (for child
abuse or neglect) or in Welfare and Institutions Code section 15630 (for elder or dependent
adult abuse or neglect).
37A-317 (Revised 01/2020) 2
Failure to comply with the requirements of Penal Code Section 11166 or Welfare and
Institutions Code Section 15630 is a misdemeanor, punishable by up to six months in a
county jail, by a fine of one thousand dollars ($1,000), or by both imprisonment and fine. For
further details about these requirements, consult Penal Code sections 11164 and Welfare
and Institutions Code section 15630, and subsequent sections.
8. SOCIAL SECURITY NUMBER OR OTHER TAXPAYER IDENTIFICATION NUMBER
Disclosure of your tax identification number on your application is mandatory. You may
provide either your Social Security Number, your Federal Employer Identification Number,
or Individual Taxpayer Identification Number, as applicable. Section 30 of the Business
and Professions Code and Public Law 94-455 (42 USCA 405 (c) (2) (c)) authorizes
collection of these tax identification numbers. Your tax identification number will not be
deemed a public record and shall not be open to the public. Your tax identification number
will be used exclusively for tax enforcement purposes, for purposes of compliance with any
judgment or order for family support in accordance with section 17520 of the Family Code,
or for verification of licensure or examination status by a licensing or examination entity
which utilizes a national examination and where licensure is reciprocal with the requesting
state. If you fail to disclose your tax identification number, your application for initial or
renewal license will not be processed AND you will be reported to the Franchise Tax
Board, which may assess a $100 penalty against you.
9. STATE TAX OBLIGATION
Pursuant to Business and Professions Code section 31(e), the State Board of Equalization
and the Franchise Tax Board may share taxpayer information with the Board. If a licensee
or applicant does not pay their state tax obligation, their license or registration may be
suspended.
10. NOTICE OF COLLECTION OF PERSONAL INFORMATION:
The Board of Behavioral Sciences of the Department of Consumer Affairs collects the
personal information requested in the Application for Licensure as authorized by Business
and Professions Code sections 27, 30, 114.5, 480, 4990.38, as well as sections 4996.2,
4996.6, 4996.17, 4996.18, 4996.23, 4996.23.1, 4996.23.2, 4996.23.3, 4996.25, 4996.26;
Title 16 of the California Code of Regulations Sections 1805, 1806, 1870 and 1870.1; and
the Information Practices Act. The Board uses this information principally to identify and
evaluate applicants for licensure, issue and renew licenses, and enforce licensing standards
set by statutes and regulations.
Mandatory Submission. Submission of the requested information is mandatory. The
Board cannot consider your application for registration, licensure or renewal unless you
provide all of the requested information.
37A-317 (Revised 01/2020) 3
Access to Personal Information. You may review the records maintained by the Board
of Behavioral Sciences that contain your personal information, as permitted by the
Information Practices Act. See below for contact information.
Possible Disclosure of Personal Information. We make every effort to protect the
personal information you provide us. The information you provide, however, may be
disclosed in the following circumstances:
• In response to a Public Records Act request (Government Code section 6250 and
following), as allowed by the Information Practices Act (Civil Code section 1798 and
following);
• To another government agency as required by state or federal law; or
• In response to a court or administrative order, a subpoena, or a search warrant.
Contact Information. For questions about this notice or access to your records, you may
contact the Board at (916) 574-7830 or by email at BBS.info@dca.ca.gov. For questions
about the Department of Consumer Affairs’ privacy policy or the Information Practices Act,
you may contact the Department of Consumer Affairs, 1625 North Market Blvd.,
Sacramento, CA 95834, (800) 952-5210 or email dca@dca.ca.gov.
37A-317 (Revised 01/2020) 4
APPLICATION FOR LICENSURE
LICENSED CLINICAL
SOCIAL WORKER
In-State Applicant
Office Use Only:
Carefully read the Application Instructions FIRST
)i(
BBS
Board
of
Behavioral
Sciences
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Attach $250 Fee ASW Number: _______________
SSN or ITIN*
Birth Date: mm/dd/yyyy
E-Mail Address
Legal Name** Last
First
Middle
If you have ever been known by another name, list the full name(s) and dates of use below
(attach any additional names and dates):
Full Name
Dates of Use (from/to)
Full Name
Dates of Use (from/to)
Public Address of Record*** Number and Street
City
State
Zip Code
Phone
Have you ever served in the United States Armed Forces or the
Yes, Currently No
California National Guard? (OPTIONAL)
Yes, Previously
* Disclosure of your tax identification number is mandatory. You may provide either your Social Security
Number, your Federal Employer Identification Number, or Individual Taxpayer Identification Number, as
applicable. This number must match the number you provide on your fingerprint forms. See Important
Information for Applicants for more information about how your tax identification number is used.
** You must use your legal name. Your “legal name” is the name established legally by your birth
certificate, marriage or domestic partnership certificate, or divorce decree (for example).
*** The address you enter on this application is public information and will be placed on the Internet
pursuant to Business and Professions Code section 27. All correspondence from the Board will be
mailed to this address. If you do not want your home or work address available to the public, use an
alternate mailing address such as a post office box.
37A-200 (Revised 01/2021) Page 1 of 3
Applicant Name: Last First Middle
□ □
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1. Have you ever applied for or been issued a license, registration or certificate
Yes No
to practice clinical social work or any other health care profession in
California or any other state?
If YES, provide the information requested below (continue on an additional
sheet if needed):
State
Type of License, Registration
or Certificate
License, Registration
or Certificate Number
Date
Issued
Status
2. Within the 7 years preceding your submission
of this application, were you denied a
professional health care license (“license”
includes registrations, certificates, or other
means to engage in practice) OR had a
professional health care license privilege
suspended, revoked, or otherwise disciplined,
OR voluntarily surrendered any such license in
California or any other state or territory of the
United States, or by any other governmental
agency or a foreign country?
Yes No
If YES, we recommend that you complete Part C
of the Background Statement form, available on
the Board’s website, to facilitate processing of
your application.
We recommend that you answer “Yes” even if
you have previously reported it to the Board, and
indicate the type of professional license that was
denied, suspended, disciplined, or surrendered,
including the date(s) of the denial, suspension,
disciplinary action, You do not need to resubmit
documentation previously on file.
3. Have you completed the following? See Application Instructions for specific requirements. If
coursework or training is not identified on transcripts, submit a copy of certificate of completion.
A. Child Abuse Assessment & Reporting in California (7 hours)
B. Human Sexuality (10 hours)
C. Alcoholism & Other Chemical Dependency (15 hours)
D. Spousal or Partner Abuse Assessment, Detection and Intervention
(See Application Instructions for number of hours required)
E. Aging, Long-Term Care & Elder/Dependent Adult Abuse (10 hours)
F. Suicide Risk Assessment and Intervention (6 hours)
37A-200 (Revised 01/2021) Page 2 of 3
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Applicant Name: Last First Middle
□ □
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4. Were you a paid employee for all or a portion of your supervised experience? Yes No
If YES, attach a copy of your W-2(s) as described in the Application
Instructions.
5. Were you a volunteer for any of your supervised experience? Yes No
If YES, attach a copy of the letter from your employer verifying voluntary
status.
BACKGROUND QUESTIONS – RESPONSE IS VOLUNTARY.
Providing an answer to the following questions is voluntary. Providing responses now, instead
of waiting for the Board to receive your fingerprint results, will facilitate processing of your
application. Your decision not to disclose information will not be a factor in the Board’s decision
to grant or deny an application. For more information, see the Criminal Conviction FAQ.
A. Have you been convicted of, pled guilty to, or
pled nolo contendere to any misdemeanor or
felony in the United States, its territories, or a
foreign country?
B. Is any criminal action pending against you,
or are you currently awaiting judgment and
sentencing following entry of a plea or jury
verdict?
Yes No
If YES, we recommend that you complete Part A
of the Background Statement form, available on
the Board’s website, to facilitate processing of
your application.
If the conviction(s) have been previously reported
to the Board, we recommend that you include a
written statement listing each conviction, including
the date(s) of the conviction(s). You do not need
to resubmit documentation previously on file.
Yes No
If YES we recommend that you complete Part B of
the Background Statement form, available on the
Board’s website, to facilitate processing of your
application.
NOTE: Knowingly making a false statement of fact that is required to be revealed in this
application may be grounds for denial of this application.
Signature of Applicant: ______________________________________ Date:_____________
37A-200 (Revised 01/2021) Page 3 of 3
)¼(
BBS
□ □
□
□
□ □ □
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:
o Use a separate form for each supervisor
o Provide an original signature in ink and have
and employer the signer initial any changes
o Make sure this form is complete and o Submit with your Application for Licensure
correct prior to signing
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 01/2019) 1 of 2
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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
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,
workshops, seminars, training sessions or conferences and direct supervisor contact*
(Maximum 1,000 overall):
B.
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
additional hours of face-to-face group supervision provided for every week in which more
than 10 hours of direct clinical counseling was performed?
Yes
No
*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 SIGNATURE REQUIRED
37A-201 (Revised 01/2019) 2 of 2
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BBS APPLICATION FOR LICENSURE LICENSED CLINICAL SOCIAL WORKER (California)

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