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BBS ASSOCIATE CLINICAL SOCIAL WORKER REGISTRATION (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
APPLICATION FOR
ASSOCIATE CLINICAL SOCIAL WORKER
REGISTRATION
Dear Applicant:
Thank you for your interest in becoming registered in California as an
Associate Clinical Social Worker. Included in this packet are the following
forms and documents:
1. Application Instructions
2. Important Information for ASW Applicants
3. Application for Registration as an ASW
4. Verification of License or Registration in Another State or Country
5. Important Live Scan Information and Instructions
6. Request for Live Scan Service Form
BOARD OF BEHAVIORAL SCIENCES
)i(
BBS
Board
of
Behavioral
Sciences
I
APPLICATION FOR
ASSOCIATE CLINICAL
SOCIAL WORKER
REGISTRATION
Application Instructions
Read Carefully Before Completing Your Application
Submit your completed application to: Board of Behavioral Sciences
1625 North Market Blvd., Suite S200
Sacramento, CA 95834
VETERANS HONORABLY DISCHARGED - EXPEDITED REVIEW
The Board is required to expedite the licensure process for an applicant who is an honorably
discharged veteran 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 MILITARY DUTY - EXPEDITED
REVIEW
The Board is required to expedite the licensure process for an applicant whose spouse or
partner or partner by way of another legal union, is an active duty member of the U.S. Armed
Forces and meets other criteria pursuant to BPC section 115.5. 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, 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.
NOTE: If you are applying for a subsequent (second or third) ASW registration, please use the
Application for Subsequent ASW Registration Number .
37A-530 (Revised 07/2020) 1
A. APPLICATION
Instructions Document(s) Required
• Complete all sections of the Application for Associate Clinical Social
Worker Registration 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).
• Email Address: The Board strongly recommends submission of your
email address to facilitate communication.
Completed and signed
Application for
Associate Clinical
Social Worker
Registration
B. FEE
Instructions Document(s) Required
Attach a $75.00 check or money order made payable to the
Behavioral Sciences Fund. This is an earned fee for evaluation of
your application and is NOT REFUNDABLE.
$75.00 check or money
order payable to the
Behavioral Sciences Fund
C. FINGERPRINTS
Instructions Document(s) Required
The Board requires a Department of Justice (DOJ) and Federal Bureau
of Investigation (FBI) criminal history background check on all applicants.
If you currently reside in California: Read the Instructions for Live
Scan Fingerprinting and complete the Request for Live Scan Service
form included in this application packet.
If you currently reside
in California: Submit
the second copy of
your completed
• The information on this form must match the information you
Request for Live Scan
provide on your application.
Service Applicant
• DO NOT COMPLETE FINGERPRINTS MORE THAN 60 DAYS
Submission form.
PRIOR TO SUBMITTING YOUR APPLICATION. Fingerprint results
without an application on file will only be held for 6 months.
If you currently reside out of state: You must use the "hard card"
fingerprint method unless you can access a California Live Scan
Service operator. To request fingerprint hard cards, send an email to
BBS.Fingerprint@dca.ca.gov with "Fingerprint Hard Cards" in the
subject line, and we will mail them to you.
If you currently reside
out of state:
Submit two completed
fingerprint hard cards
(FBI and DOJ)
• DO NOT SUBMIT YOUR FINGERPRINTS TO THE BOARD UNTIL
YOU HAVE SUBMITTED YOUR APPLICATION – we are unable to
process them until your application is received.
• DOJ processing time for hard card fingerprints is 8 or more weeks.
37A-530 (Revised 07/2020) 2
D. VERIFICATION OF LICENSE/REGISTRATION IN ANOTHER STATE OR COUNTRY
Instructions Document(s) Required
Include certified statement(s) from each state or country where you hold
or have held a license or registration to practice clinical social work. This
verification may be provided in one of the following ways:
• Emailed to the Board directly from the other state to
BBSLicCerts@dca.ca.gov
• Sent to the Board directly from the other state IN AN ENVELOPE
SEALED BY THE STATE LICENSING AGENCY
• Enclosed with the application IN AN ENVELOPE SEALED BY
THE STATE LICENSING AGENCY.
Verification of
licensure or
registration emailed or
sent to the Board in a
SEALED ENVELOPE
OR EMAILED AS
DIRECTED
E. OFFICIAL TRANSCRIPTS
Instructions Document(s) Required
Provide official transcript(s) verifying your master’s degree from a
program accredited by the Commission on Accreditation of the Council
on Social Work Education (CSWE). The degree title and date of
conferral must be posted. An applicant with a degree from a program
which is a candidate for accreditation by the CSWE is eligible for ASW
registration. Submit your transcripts as follows:
• Mailed to the Board IN AN ENVELOPE SEALED BY THE
EDUCATIONAL INSTITUTION; or
• Sent electronically to the Board at BBSLCSWtranscripts@dca.ca.gov
(for questions about electronic submission, see FAQ).
Official transcript(s)
with degree title and
date of conferral
posted.
MUST BE SENT
ELECTRONICALLY OR
MAILED IN A SEALED
ENVELOPE AS
DIRECTED
F. DEGREE EARNED OUTSIDE OF THE UNITED STATES
Instructions Document(s) Required
If your degree was earned from a school in another country, you must
obtain a comprehensive evaluation of your degree in order to determine
equivalency to a master's from a program accredited by the Council on
Social Work Education. The Board has the right to request additional
information and to make the final determination of whether a degree
meets all requirements including coursework, regardless of evaluation
or accreditation. MUST BE IN AN ENVELOPE SEALED BY THE
EVALUATING AGENCY. In addition to the evaluation, a transcript is
required as stated in E. above.
Degree evaluation by a
foreign credential
evaluation service (if
applicable). MUST BE
IN A SEALED
ENVELOPE
37A-530 (Revised 07/2020) 3
G. COURSEWORK IN CALIFORNIA LAW AND PROFESSIONAL ETHICS
Instructions Document(s) Required
All applicants are required to complete coursework in California Law and
Professional Ethics for Clinical Social Workers, as follows:
• Applicants with a California Degree: No documentation is
required. All accredited social work schools in California have
notified the Board that their graduates have met this requirement.
Applicants with an
Out-of-State Degree
ONLY:
Proof of completion of
12-Hours California
Law and Ethics Course
• Applicants with an Out-of-State Degree: Attach a certificate of
completion for 12 hours of coursework that covers, at minimum, all
of the following content pertaining to California Law and Ethics:
Required course content: Advertising, scope of practice, scope of
competence, treatment of minors, confidentiality, dangerous patients,
psychotherapist-patient privilege, recordkeeping, patient access to
records, state and federal laws related to confidentiality of patient health
information, dual relationships, child abuse, elder and dependent adult
abuse, online therapy, insurance reimbursement, civil liability,
disciplinary actions and unprofessional conduct, ethics complaints and
ethical standards, termination of therapy, standards of care, relevant
family law, therapist disclosures to patients, the application of legal and
ethical standards in different types of work settings, and licensing law
and process.
This course may be taken from a school that holds a CSWE
accreditation, a regional or national institutional accreditation
recognized by the United States Department of Education (USDE), or a
school approved by the Bureau for Private Postsecondary Education
(BPPE).
H. ADDITIONAL COURSEWORK REQUIRED PRIOR TO APPLICATION FOR
LICENSURE
Instructions Document(s) Required
See Important Information for ASW Applicants for the list of courses that
must be completed prior to submitting your Application for Licensure.
You may submit documentation of completion now, or wait until you
apply for licensure.
None at this time.
37A-530 (Revised 07/2020) 4
BBS
Board
of
Behavioral
Sciences
Important Information for
ASSOCIATE CLINICAL
SOCIAL WORKER
APPLICANTS
1. POST-DEGREE EXPERIENCE AND THE 90-DAY RULE
Post-degree hours of experience will only begin accruing from the issuance date of your
Associate registration, unless the Board receives your application for registration within
90 days from the date your qualifying degree was conferred, as posted on your
transcript. Applicants may not work in a private practice or professional corporation until
the Associate registration has been issued.
Special note for applicants graduating on or after January 1, 2020:
Hours may only be accepted under the “90-day-rule” described above IF the hours are
obtained at a workplace that, prior to the applicant gaining hours, required Live Scan
fingerprinting. The applicant must provide documentation to the Board consisting of a
copy of the processed “State of California Request for Live Scan Service” form. This
form must be submitted with the Application for Licensure in order for the hours gained
between graduation and registration issuance to be accepted. A copy of the processed
form is the ONLY acceptable documentation specified in law. There are no exceptions.
See the FAQ about the 90-day rule for more information about the new requirements.
2. EXAM REQUIREMENT FOR RENEWAL OF REGISTRATION
Registrants Must Take a California Law and Ethics Exam to Renew:
After your Associate registration is issued, you will be required to take the LCSW
California Law and Ethics Exam. Your registration will not be renewable until the exam
has been taken. You will be given instructions on applying for this exam once your
registration has been issued.
About the California Law and Ethics Exam
The California Law and Ethics Exam is designed to assess an applicant's knowledge of
and ability to apply legal and ethical standards relating to clinical practice. See the
Exams tab of the Board’s website for more information.
3. SUPERVISION AND WORK SETTING REQUIREMENTS
You are required to work under the supervision of a qualified supervisor in order to gain
hours of experience toward licensure. In addition, it is against the law for you to provide
clinical services in a private practice setting or in a professional corporation without a
registration and without the required supervision. See the Publications section of the
“Applicants/LCSW” tab on the Board’s website for more information and additional
requirements about supervision and work settings.
37A-518 (Revised 07/2020) 1
4. MAXIMUM RENEWALS AND ISSUANCE OF SUBSEQUENT REGISTRATIONS
Your registration can be renewed five (5) times, for a total six (6)-year length. If you need
to retain a registration after this time, you will need to apply for a subsequent registration
number. A subsequent registration can only be issued to applicants who have passed
the LCSW California Law and Ethics Exam (or the former LCSW Standard Written
Exam).
5. ABANDONMENT OF APPLICATION
In accordance with Title 16, California Code of Regulations (CCR) section 1806, an
application shall be deemed abandoned in either of the following circumstances:
• 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 OR
• You do not complete your application within one (1) year after it has been filed.
To re-open an abandoned application, you must submit a new application, fee and all
required documentation, as well as meet all current requirements in effect at the time the
new application is submitted.
6. 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 (BPC) 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 within 30 days of any change of address.
7. STATUTES AND REGULATIONS
To obtain a copy of the Board’s Statutes and Regulations, please download it from the
Board’s website.
37A-518 (Revised 07/2020) 2
8. ADDITIONAL TRAINING OR COURSEWORK REQUIRED FOR LICENSURE
Verification of training or coursework can be submitted with this application OR with the
Application for Licensure. Only coursework that meets the criteria specified by law will be
accepted. For more information, see the Board’s Statutes and Regulations.
Course
Length
Content Required
Suicide Risk Assessment and
Intervention
Required of those
submitting an application
for licensure on or after
January 1, 2021
(otherwise will be required
upon license renewal)
6 hours of
coursework or
applied
experience
See
BPC section
4996.27
Child Abuse Assessment and
Reporting in California
All applicants 7 hours
See BPC section 28
and 16CCR section
1807.2. Course
must be based on
California law.
Human Sexuality All applicants 10 hours
16 CCR section
1807
Alcoholism and Chemical
Substance Abuse &
Dependency
All applicants 15 hours
16 CCR section
1810
Aging, Long Term Care and
Elder/Dependent Adult Abuse
MSW program after
10 hours BPC section
4996.25(a)
California Cultures and the
Social and Psychological
Implications of Socioeconomic
Position (OUT-OF-STATE)
All applicants with out-of-
state education
15 hours or 1
semester unit
BPC section
4996.17.2
Spousal/Partner Abuse
Assessment, Detection, and
Intervention (OUT-OF-STATE)
All applicants with out-of-
state education
15 hours BPC 4996.17.2
Spousal/Partner Abuse
Assessment, Detection, and
Intervention
(IN-STATE)
All in-state 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)
37A-518 (Revised 07/2020) 3
I
9. AMERICANS WITH DISABILITIES ACT
The Board does not discriminate on the basis of disability in employment or in the
admission and access to its programs or activities. The Executive Officer of the Board has
been designated to coordinate and carry out this agency’s compliance with the
nondiscrimination requirements of Title II of the ADA. Information concerning the
provisions of the ADA, and the rights provided hereunder, are available from the ADA
coordinator.
10. MANDATORY REPORTER
Under California law each person licensed by the Board of Behavioral Sciences is a
“mandated reporter” for both child, elder and/or dependent adult abuse or neglect
purposes. 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). Failure to comply with the requirements of section
11166 and 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.
11. 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.
37A-518 (Revised 07/2020) 4
12. 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 registrant does not pay their state tax obligation, the individual’s ASW
registration may be suspended.
13. NOTICE OF COLLECTION OF PERSONAL INFORMATION
The Board of Behavioral Sciences of the Department of Consumer Affairs collects the
personal information requested on this form as authorized by Business and Professions
Code sections 27, 30, 114.5, 480, 4996.2, 4996.17, 4996.18, Article 2 of Chapter 14
(commencing with section 4992), Title 16 of the California Code of Regulations sections
1805 and 1806, 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.
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-518 (Revised 07/2020) 5
APPLICATION FOR
ASSOCIATE CLINICAL
SOCIAL WORKER
REGISTRATION
Office Use Only:
Carefully read the Application Instructions FIRST
BBS
Board
of
Behavioral
Sciences
□ □
□
Attach a $75 Fee
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-520 (Revised 07/2020) Page 1 of 3
Applicant Name: Last First Middle
□ □
□ □
□
□
□ □
□
□
1. Have you ever applied for or been issued a license, registration or Yes No
certificate 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. If you hold or have held a license or registration to Yes No
practice clinical social work outside of California,
N/A
have you attached an Out-of-State Verification of
License or Registration form for each license or
registration held?
4. Have you submitted official transcripts verifying your Yes – Sealed Transcripts via Mail
qualifying master’s degree? See Application
Yes – Electronic Transcripts
Instructions for transcript requirements.
No
37A-520 (Revised 07/2020) Page 2 of 3
Applicant Name: Last First Middle
□
□
□ □
□
□
□
5. Applicants with an Out-of-State Degree: Yes No
Have you completed a 12-hour course in California Law and N/A
Professional Ethics for Clinical Social Workers that covered ALL
of the topics listed in the Application Instructions item G as
required by Business and Professions Code section 4996.17.2?
If YES, enclose a certificate of completion.
Note: Applicants with a degree earned in California have already
met this requirement and no documentation is necessary.
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-520 (Revised 07/2020) Page 3 of 3
BBS
□ □
I I I I I
I I I I I
□ □
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
OUT-OF-STATE LICENSE OR REGISTRATION VERIFICATION
APPLICANT: Complete this section authorizing release of information by another state board or
licensing agency. Mail this form and any necessary fees to that state board/licensing agency.
Verification For: Applicant Applicant’s Supervisor
Name of California Applicant:
Last
First
Middle
Date of Birth
Name of Individual to be Verified:
Last
First
Middle
License Number
I hereby authorize the release of my information to the California Board of Behavioral Sciences
Signature of individual to be verified: _________________________________ Date:________
STATE BOARD/LICENSING AGENCY: Please return this form to the above address.
1. Full name as shown in your records: ___________________________________________________
2. License or Registration Title: _________________________________________________________
3. License or Registration Status: _______________________________________________________
Issue Date: __________ Expiration Date: ___________
4. Any disciplinary action? Yes No If YES, attach an explanation.
Signature of Person Completing Form
Printed Name and Title
State Board or Licensing Agency Name
Date
State Board/Licensing Agency
Stamp Here
State Phone Number
37A-526 (Revised 01/2020)
)¼(
BBS
STATE OF CALIFORNIA - BUSINESS, CONSUMER SERVICES, ANDHOUSING 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
INSTRUCTIONS FOR LIVE SCAN FINGERPRINTING
AND PRIVACY NOTICES
Live Scan Fingerprinting is available only in California. Live Scan fingerprint results will be
submitted to the Department of Justice (DOJ) and the Federal Bureau of Investigation
(FBI) electronically.
If you need to have your fingerprints taken in another state, you must use the "hard card"
fingerprint method. To request hard cards and instructions, send an email to
BBS.Fingerprint@dca.ca.gov with "Fingerprint Hard Cards" in the subject line, and include
your mailing address. Please be advised that the DOJ processing time for hard card
fingerprints is a minimum of 8 to 12 weeks, or longer. In order to avoid processing delays
and additional costs that result from invalid fingerprint cards, fingerprints must be taken at a
law enforcement agency in the state of residence.
Fingerprint Fees - Paid to Live Scan Site
If you have your prints taken via Live Scan, you must pay the fingerprint fees below
directly to the site where you have your Live Scan fingerprints taken:
DOJ FINGERPRINT PROCESSING FEE: $32.00
FBI FINGERPRINT PROCESSING FEE: $17.00
In addition to these processing fees, there may be a service charge associated with
the Live Scan site you visit. The Live Scan service site will collect the above fees at the
time you are fingerprinted. The Live Scan service charge may vary from location to
location.
Complete the Request for Live Scan Service Form
You must complete and submit the attached Request for Live Scan Service form at the
Live Scan site. Make sure that the information provided in Section 3 of the form matches
the information on your BBS application. Once your fingerprints have been scanned, the
Live Scan Operator will complete Section 4 of this form and return the second and third
copies to you.
The second copy of this form, with Section 4 completed by the Live Scan Operator,
must be MAILED to the BBS in order to retrieve your fingerprint results from the DOJ.
Retain the third copy for your records as a proof of payment.
37A-648 (Revised 06/2020) 1
Live Scan Fingerprint Locations
You must visit an approved Live Scan Service Site. Most local Police and Sheriff
Departments offer the Live Scan fingerprinting service. Some large school districts,
passport services, and stores with generalized fingerprinting expertise may also offer Live
Scan. A current listing of Live Scan sites is available on the DOJ website at
https://oag.ca.gov/fingerprints/locations.
Consider calling the Live Scan service provider for hours of operation, fees, and
appointment times if necessary. You must present valid photo identification (i.e., driver’s
license, military ID, or passport) at the Live Scan site.
Filling Out Your Live Scan Form
To facilitate prompt and accurate processing, please TYPE or print legibly in ink.
SECTION 1: Type of Application: LIC/CERT/PERMIT
Check the box for the applicable registration or license you are applying for with the BBS.
Even if you are applying for more than one registration or license type, CHECK THE BOX
FOR ONLY ONE LICENSE TYPE. Your fingerprint results will be put towards ALL
registrations and licenses you hold. You do not need to pay or be fingerprinted for each
individual BBS license type.
SECTION 2: This section is already completed.
SECTION 3:
Name of Applicant: Enter your full name
Alias: Indicate all other names used
Date of Birth: Indicate your month/day/year of birth
Sex: Mark the appropriate box
Height: Indicate your height in feet and inches
Weight: Indicate your weight in pounds (lbs.)
Eye Color: Indicate eye color abbreviation:
BLK - Black
GRY - Gray
MAR - Maroon
BLU - Blue
GRN - Green
PNK – Pink
BRO - Brown
HAZ - Hazel
MUL - Multicolor
Hair Color: Indicate hair color abbreviation:
BAL - Bald
BRO - Brown
SDY - Sandy
BLK - Black
GRY - Gray
WHI - White
BLN - Blonde
RED - Red
37A-648 (Revised 06/2020) 2
Place of Birth:
Indicate the state or country of birth
Social Security
Enter your SSN or individual taxpayer ID number. Must match the
Number:
number provided on your application.
Driver’s License
Enter your Driver’s license number if you have one.
No:
Address: Enter a mailing address of your choice. You may use a business
address, your home address, or any current address. This
address will not be viewable by the public, and will be used
solely for the BBS’ records.
Your BBS File number:
Enter your BBS file number. If you are a brand new applicant and do not currently hold an
identifying number, leave this line blank.
If Resubmission, list Original ATI No.
This is only used for a second fingerprinting due to a prior fingerprint rejection. The ATI No.
allows you to be re-fingerprinted without paying the DOJ and FBI processing fee (service
charges may still apply.)
Applicant Signature
Sign and date the application to indicate that you have read the included Privacy Notice,
Privacy Act Statement and Applicant’s Privacy Rights.
SECTION 4:
To be completed by the Live Scan operator.
37A-648 (Revised 06/2020) 3
REQUEST FOR LIVE SCAN SERVICE
Privacy Notice
As Required by Civil Code § 1798.17
Collection and Use of Personal Information. The California Justice Information Services
(CJIS) Division in the Department of Justice (DOJ) collects the information requested on this
form as authorized by Business and Professions Code sections 4600-4621, 7574-7574.16,
26050-26059, 11340-11346, and 22440-22449; Penal Code sections 11100-11112, and
11077.1; Health and Safety Code sections 1522, 1416.20-1416.50, 1569.10-1569.24, 1596.80-
1596.879, 1725-1742, and 18050-18055; Family Code sections 8700-87200, 8800-8823, and
8900-8925; Financial Code sections 1300-1301, 22100-22112, 17200-17215, and 28122-
28124; Education Code sections 44330-44355; Welfare and Institutions Code sections 9710-
9719.5, 14043-14045, 4684-4689.8, and 16500-16523.1; and other various state statutes and
regulations. The CJIS Division uses this information to process requests of authorized entities
that want to obtain information as to the existence and content of a record of state or federal
convictions to help determine suitability for employment, or volunteer work with children, elderly,
or disabled; or for adoption or purposes of a license, certification, or permit. In addition, any
personal information collected by state agencies is subject to the limitations in the Information
Practices Act and state policy. The DOJ's general privacy policy is available at
http://oag.ca.gov/privacy-policy.
Providing Personal Information. All the personal information requested in the form must be
provided. Failure to provide all the necessary information will result in delays and/or the
rejection of your request.
Access to Your Information. You may review the records maintained by the CJIS Division in
the DOJ that contain your personal information, as permitted by the Information Practices Act.
See below for contact information.
Possible Disclosure of Personal Information. In order to process applications pertaining to
Live Scan service to help determine the suitability of a person applying for a license,
employment, or a volunteer position working with children, the elderly, or the disabled, we may
need to share the information you give us with authorized applicant agencies. The information
you provide may also be disclosed in the following circumstances:
• With other persons or agencies where necessary to perform their legal duties, and their
use of your information is compatible and complies with state law, such as for
investigations or for licensing, certification, or regulatory purposes.
• To another government agency as required by state or federal law.
Contact Information. For questions about this notice or access to your records, you may
contact the Associate Governmental Program Analyst at the DOJ's Keeper of Records at (916)
210-3310, by email at keeperofrecords@doj.ca.gov, or by mail at: Department of Justice Bureau
of Criminal Information & Analysis Keeper of Records P.O. Box 903417 Sacramento, CA
94203-4170.
REQUEST FOR LIVE SCAN SERVICE
Privacy Act Statement
Authority. The FBI's acquisition, preservation, and exchange of fingerprints and associated
information is generally authorized under 28 U.S.C. 534. Depending on the nature of your
application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L.
92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and
associated information is voluntary; however, failure to do so may affect completion or approval
of your application.
Principal Purpose. Certain determinations, such as employment, licensing, and security
clearances, may be predicated on fingerprint-based background checks. Your fingerprints and
associated information/biometrics may be provided to the employing, investigating, or otherwise
responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other
fingerprints in the FBI's Next Generation Identification (NGI) system or its successor systems
(including civil, criminal, and latent fingerprint repositories) or other available records of the
employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints
and associated information/biometrics in NGI after the completion of this application and, while
retained, your fingerprints may continue to be compared against other fingerprints submitted to
or retained by NGI.
Routine Uses. During the processing of this application and for as long thereafter as your
fingerprints and associated information/biometrics are retained in NGI, your information may be
disclosed pursuant to your consent, and may be disclosed without your consent as permitted by
the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the
Federal Register, including the Routine Uses for the NGI system and the FBI's Blanket Routine
Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental, or
authorized non-governmental agencies responsible for employment, contracting, licensing,
security clearances, and other suitability determinations; local, state, tribal, or federal law
enforcement agencies; criminal justice agencies; and agencies responsible for national security
or public safety.
REQUEST FOR LIVE SCAN SERVICE
Noncriminal Justice Applicant's Privacy Rights
As an applicant who is the subject of a national fingerprint-based criminal history record check for a
noncriminal justice purpose (such as an application for employment or a license, an immigration or
naturalization matter, security clearance, or adoption), you have certain rights which are discussed
below.
• You must be provided written notification
1
that your fingerprints will be used to check the
criminal history records of the FBI.
• You must be provided, and acknowledge receipt of, an adequate Privacy Act Statement
when you submit your fingerprints and associated personal information. This Privacy Act
Statement should explain the authority for collecting your information and how your
information will be used, retained, and shared.
2
• If you have a criminal history record, the officials making a determination of your suitability for
the employment, license, or other benefit must provide you the opportunity to complete or
challenge the accuracy of the information in the record
.
• The officials must advise you that the procedures for obtaining a change, correction, or
update of your criminal history record are set forth at Title 28, Code of Federal Regulations
(CFR), Section 16.34.
• If you have a criminal history record, you should be afforded a reasonable amount of time to
correct or complete the record (or decline to do so) before the officials deny you the
employment, license, or other benefit based on information in the criminal history record
.
3
You have the right to expect that officials receiving the results of the criminal history record check
will use it only for authorized purposes and will not retain or disseminate it in violation of federal
statute, regulation or executive order, or rule, procedure or standard established by the National
Crime Prevention and Privacy Compact Council.
4
If agency policy permits, the officials may provide you with a copy of your FBI criminal history record
for review and possible challenge. If agency policy does not permit it to provide you a copy of the
record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI.
Information regarding this process may be obtained at https://www.fbi.gov/services/cjis/identity-
history-summary-checks
If you decide to challenge the accuracy or completeness of your FBI criminal history record, you
should send your challenge to the agency that contributed the questioned information to the FBI.
Alternatively, you may send your challenge directly to the FBI. The FBI will then forward your
challenge to the agency that contributed the questioned information and request the agency to verify
or correct the challenged entry. Upon receipt of an official communication from that agency, the FBI
will make any necessary changes/corrections to your record in accordance with the information
supplied by that agency. (See 28 CFR 16.30 through 16.34.) You can find additional information on
the FBI website at https://www.fbi.gov/about-us/cjis/background-checks
1 Written notification includes electronic notification, but excludes oral notification
2 https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement
3 See 28 CFR 50.12(b) 4 See U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. §
14616), Article IV(c)
4 See U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616), Article IV(c)
SECTION 1
ORI: A0462
(Code assigned by DOJ)
Type of Application: LIC/CERT/PERMIT
Type of License: (Mark Only ONE)
rriage a nd F amil Th
Ma y erapist
Educational Psychologist
Clinical Social Worker
Professional Clinical Counselor
SECTION 2
Agency Authorized to Receive Criminal Record
Information:
Board of Behavioral Sciences
1625 North Market Blvd. Suite S-200
Sacramento CA 95834
Mail Code: 01484
Contact Name: Fingerprint Unit
Contact Phone: (916) 574-7859
SECTION 3
Name of Applicant: ______________________________
(Please Print) Last
Alias: _________________________________________
Last First
Date of Birth: ____________ Sex: Male Female
Height: ________________ Weight: _______________
Eye Color: _____________ Hair Color: ____________
Place of Birth: __________________________________
Social Security Number: __________________________
_____________________________ ______
First MI
Driver’s License No.: ____________________
Billing No.: APPLICANT MUST PAY
Address:
______________________________________
Number and Street
________________________ ____ ________
City State Zip
BBS File Number: __________________________
If Resubmission, list Original ATI No.:
_________________________________________
(Must provide proof of rejection)
BBS Applicant: Please mail a copy of this
form to the address in Section 2 with your
BBS application.
Level of Service: DOJ FBI
I have received and read the included Privacy Notice, Privacy Act Statement and Applicant’s Privacy Rights.
Applicant Signature: _____________________________________ Date: __________
SECTION 4
Live Scan Transaction Completed By: ____________________________________ Date: _____________
Transmitting Agency: ___________________________________________ LSID: __________________
ATI No.: _________________________ Amount Collected/Billed: _______________________________
ORIGINAL – Live Scan Operator SECOND COPY – Requesting Agency THIRD COPY - Applicant
37A-649 (Revised 06/2020)
State of California
REQUEST FOR LIVE SCAN SERVICE
APPLICANT
BCII 8016 (04/2020)
Applicant Submission
SECTION 1
ORI: A0462
(Code assigned by DOJ)
Type of Application: LIC/CERT/PERMIT
Type of License: (Mark Only ONE)
Th
Marriage and Family erapist
Educational Psychologist
Clinical Social Worker
Professional Clinical Counselor
SECTION 2
Agency Authorized to Receive Criminal Record
Information:
Board of Behavioral Sciences
1625 North Market Blvd. Suite S-200
Sacramento CA 95834
Mail Code: 01484
Contact Name: Fingerprint Unit
Contact Phone: (916) 574-7859
SECTION 3
Name of Applicant: ______________________________
(Please Print) Last
Alias: _________________________________________
Last First
Date of Birth: ____________ Sex: Male Female
Height: ________________ Weight: _______________
Eye Color: _____________ Hair Color: ____________
Place of Birth: __________________________________
Social Security Number: __________________________
_____________________________ ______
First MI
Driver’s License No.: ____________________
Billing No.: APPLICANT MUST PAY
Address:
______________________________________
Number and Street
________________________ ____ ________
City State Zip
BBS File Number: __________________________
If Resubmission, list Original ATI No.:
_________________________________________
(Must provide proof of rejection)
BBS Applicant: Please mail a copy of this
form to the address in Section 2 with your
BBS application.
Level of Service: DOJ FBI
I have received and read the included Privacy Notice, Privacy Act Statement and Applicant’s Privacy Rights.
Applicant Signature: _____________________________________ Date: __________
SECTION 4
Live Scan Transaction Completed By: ____________________________________ Date: _____________
Transmitting Agency: ___________________________________________ LSID: __________________
ATI No.: _________________________ Amount Collected/Billed: _______________________________
ORIGINAL – Live Scan Operator SECOND COPY – Requesting Agency THIRD COPY - Applicant
37A-649 (Revised 06/2020)
State of California
REQUEST FOR LIVE SCAN SERVICE
APPLICANT
BCII 8016 (04/2020)
Applicant Submission
SECTION 1
ORI: A0462
(Code assigned by DOJ)
Type of Application: LIC/CERT/PERMIT
Type of License: (Mark Only ONE)
arriage a nd Family Therapi
M st
Educational Psychologist
Clinical Social Worker
Professional Clinical Counselor
SECTION 2
Agency Authorized to Receive Criminal Record
Information:
Board of Behavioral Sciences
1625 North Market Blvd. Suite S-200
Sacramento CA 95834
Mail Code: 01484
Contact Name: Fingerprint Unit
Contact Phone: (916) 574-7859
SECTION 3
Name of Applicant: ______________________________
(Please Print) Last
Alias: _________________________________________
Last First
Date of Birth: ____________ Sex: Male Female
Height: ________________ Weight: _______________
Eye Color: _____________ Hair Color: ____________
Place of Birth: __________________________________
Social Security Number: __________________________
_____________________________ ______
First MI
Driver’s License No.: ____________________
Billing No.: APPLICANT MUST PAY
Address:
______________________________________
Number and Street
________________________ ____ ________
City State Zip
BBS File Number: __________________________
If Resubmission, list Original ATI No.:
_________________________________________
(Must provide proof of rejection)
BBS Applicant: Please mail a copy of this
form to the address in Section 2 with your
BBS application.
Level of Service: DOJ FBI
I have received and read the included Privacy Notice, Privacy Act Statement and Applicant’s Privacy Rights.
Applicant Signature: _____________________________________ Date: __________
SECTION 4
Live Scan Transaction Completed By: ____________________________________ Date: _____________
Transmitting Agency: ___________________________________________ LSID: __________________
ATI No.: _________________________ Amount Collected/Billed: _______________________________
ORIGINAL – Live Scan Operator SECOND COPY – Requesting Agency THIRD COPY - Applicant
State of California
REQUEST FOR LIVE SCAN SERVICE
APPLICANT
BCII 8016 (04/2020)
Applicant Submission
37A-649 (Revised 06/2020)
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BBS ASSOCIATE CLINICAL SOCIAL WORKER REGISTRATION (California)

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Completed 28 October 2020

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