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

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BBS LICENSED CLINICAL SOCIAL WORKER APPLICATION FOR LICENSURE (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
OUT-OF-STATE
APPLICATION FOR LICENSURE
For applicants with an out-of-state degree or license*
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. Guide to Out-of-State Applicant Requirements
2. Application Instructions
3. Important Information for Applicants
4. Out-of-State Application for LCSW Licensure – GENERAL
5. Application for Licensure PATH A - BY CREDENTIAL
6. Application for Licensure PATH B - BY EDUCATION AND EXPERIENCE
7. Out-of-State License or Registration Verification Form
8. Out-of-State Experience Verification Form
9. Instructions for Live Scan Fingerprinting/Request for Live Scan Service Form
BOARD OF BEHAVIORAL SCIENCES
*If you are not licensed in another state but have an Out-of-State
degree, and are currently registered as an Associate in California and
have gained experience hours in California, you may instead submit
an In-State Application for Licensure
. You may have coursework to
complete - please refer to the notice sent upon approval of your
Associate application.
)!(
BBS
Board
of
Behavioral
Sciences
GUIDE TO LCSW OUT-OF-STATE
APPLICANT REQUIREMENTS
Applicant Type
Do you meet ALL of the following requirements?
I have held a license as a Clinical Social Worker in another United States jurisdiction
for at least two years.
The license I hold is current, and has been active and unrestricted for at least two
years immediately before the date I submit my application to the Board.
The license I hold is at the highest level for independent clinical practice in that
jurisdiction.
The degree that qualified me for this license is a master’s degree obtained from a
school or department of social work that is accredited by the Commission on
Accreditation of the Council on Social Work Education (CSWE).
If YES, go to Path A (LICENSURE BY CREDENTIAL)
If NO,
Skip to Path B (LICENSURE BY EDUCATION/EXPERIENCE)
Path A – LICENSURE BY CREDENTIAL
Applicants who qualify for this path (as specified in Business and Professions Code
(BPC) section 4996.17.1) must meet all of the following requirements:
1. EXAMINATION: You must pass the California Law and Ethics Examination. You will
be eligible to take this exam after your Application for Licensure has been approved.
2. QUALIFYING DEGREE: The degree that qualified you for licensure in another
United States jurisdiction must be a master’s degree obtained from a school or
department of social work that is accredited by the CSWE.
3. COURSEWORK: You must complete the following California-specific coursework.
Courses must be taken from a school or department of social work that is accredited
by CSWE, a school holding a regional or national institutional accreditation
recognized by the U.S. Department of Education (USDE), a school approved by the
California Bureau for Private Postsecondary Education (BPPE), or an acceptable
continuing education provider. Undergraduate coursework cannot be accepted.
37A-642 (Revised 01/2021) 1
Path A – LICENSURE BY CREDENTIAL (continued)
REQUIRED CALIFORNIA-SPECIFIC COURSEWORK
Length
Content Required
California Law and Ethics 12 hours Instruction must include 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 relating 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 licensing process. See
BPC
section 4996.17.1.
California Cultures and the
Social and Psychological
Implications of Socioeconomic
Position
15 hours or 1
semester unit
Instruction must include an understanding of various
California cultures and the social and psychological
implications of socioeconomic position. See
BPC
section 4996.17.1.
Child Abuse Assessment and
7 hours Instruction must include detailed knowledge of the
Reporting in California
California Child Abuse Neglect and Reporting Act
(CANRA). It must also include assessment and
(In addition to the course provider
methods of reporting of sexual assault, neglect,
types listed above, this may be a
severe neglect, general neglect, willful cruelty or
course sponsored or offered by a
unjustifiable punishment, corporal punishment or
professional association or a local,
injury, and abuse in out-of-home care. The training
county or state department of
shall also include physical and behavioral indicators
health or mental health)
of abuse, crisis counseling techniques, community
resources, rights and responsibilities of reporting,
consequences of failure to report, caring for a
child’s needs after a report is made, sensitivity to
previously abused children and adults, and
implications and methods of treatment for children
and adults. See
BPC sections 28 and 4996.17.1
and Title 16, California Code of Regulations section
1807.2.
Suicide Risk Assessment and
Intervention
(Does not need to be California-
specific)
6 hours of
coursework
or applied
experience
• See BPC section 4996.27
for details.
Note: 1 semester unit = 15 hours; 1 quarter unit = 10 hours; 1 semester unit = 1.5 quarter units
37A-642 (Revised 01/2021) 2
Path B – LICENSURE BY EDUCATION/EXPERIENCE
Applicants who do not qualify for Path A “Licensure by Credential” must meet the
following requirements as specified in Business and Professions Code (BPC) section
4996.17.2. This is a summary - see the Application for Licensure for more information.
1. EXAMINATIONS: You must pass both of the following exams:
• California Law and Ethics Exam: You will be eligible to take this exam upon
issuance of your Associate registration or upon approval of your Application for
Licensure.
• Association of Social Work Boards - Clinical Exam: If you have already passed
this exam, the Board may be able to accept your passing score if:
o You do not currently hold a license in another state or country, your passing
score must be less than seven (7) years old;
o You currently hold a license or registration in another state or country and
the license or registration is active and in good standing at the time of
application and is not revoked, suspended, surrendered, denied or otherwise
restricted or encumbered, a passing score of any age will be accepted;
o The Board receives official verification of your passing score from the
Association of Social Work Boards. Please follow the instructions in the
Application for Licensure.
If you have not yet passed the ASWB Clinical Exam, you will be eligible to take it
after approval of your Application for Licensure and after passing the California
Law and Ethics Exam.
2. SUPERVISED EXPERIENCE: Your experience must be substantially equivalent to
California’s requirements as described below.
• If you are licensed as an LCSW in another state or country at the highest
level for independent clinical practice: Your requirements will depend on
whether you were licensed at the highest level for independent clinical practice in
a jurisdiction of the United States vs. another country. It will also depend on how
many hours were required for that license by the other state or country, as
described below:
o If you are licensed in another United States jurisdiction that requires at least
3,000 hours of experience: You do not need to submit verification of
experience.
o If you are licensed in another country: You must submit verification of 3,000
hours of substantially equivalent experience that includes 104 supervised
weeks.
o If you are licensed in another state or country that requires less than 3,000
hours of experience: You may make up the deficit using time actively
licensed in good standing in another state or country at the rate of 100 hours
37A-642 (Revised 01/2021) 3
r
Path B – LICENSURE BY EDUCATION/EXPERIENCE
per month licensed at the highest level (up to a maximum of 1,200 hours). You
do not need to submit verification of these hours.
If additional hours are needed and will be gained in California, you must first
register as an Associate and comply with all requirements for hours gained in
California.
• All other applicants: You will need to submit verification of substantially
described below: equivalent supervised experience totaling 3,000 hours as
o Experience must have been supervised by a licensed mental health professional
and gained within the six (6) years prior to the Board’s receipt of your application.
o If any experience will be obtained in California, you must first register as an
Associate and comply with all requirements for hours gained in California.
o If you are not licensed in another state or country at the highest level for
independent clinical practice, you must have 104 weeks of supervision.
For questions about supervised experience requirements, contact bbs.lcsw@dca.ca.gov
3. QUALIFYING DEGREE: You must hold a master’s degree from a CSWE-accredited
school or department of social work. If your degree was obtained outside of the United
States, you must obtain a degree evaluation in accordance with BPC section
4996.18(e).
4. 12-HOUR CALIFORNIA LAW AND ETHICS COURSE: You must complete a 12-hour
course in California Law and Ethics. This course must be completed prior to
registration as an Associate (or prior to submitting your Application for Licensure if you
do not need to apply for Associate registration). See BPC section 4996.17.2(d)(2)(F)
for course content requirements.
5. ADDITIONAL COURSEWORK: You must complete coursework in accordance with
BPC section 4996.17.2, some of which must be California-specific. See the chart
beginning on page 5 for details. If it will take you a significant amount of time to
complete your coursework, you may want to consider registering as an Associate while
you are taking the courses as it will allow you to work in California as a clinical social
worker under supervision.
The California Law and Ethics course and Additional Coursework listed under #4 and
#5 above may be taken from a CSWE accredited school or department of social work,
a school with a regional or national institutional accreditation recognized by the USDE,
a school approved by the BPPE, or an acceptable continuing education provider.
Undergraduate coursework cannot be accepted. If you are unsure whether your degree
or other coursework qualifies (or is deficient), submit your Application for Licensure and
fee, and we will provide you with the results of the evaluation. For questions about
educational requirements, contact bbs.asw@dca.ca.gov
37A-642 (Revised 01/2021) 4
ADDITIONAL COURSEWORK
LCSW OUT-OF-STATE APPLICANTS
Path B – LICENSURE BY EDUCATION/EXPERIENCE
1 semester unit = 15 hours; 1 quarter unit = 10 hours; 1 semester unit = 1.5 quarter units
Length
Content Required
a) Suicide Risk Assessment 6 hours of
See BPC section 4996.27
and Intervention coursework
or applied
experience
b) California Law and Ethics 12 hours See BPC section 4996.17.2(d)(2)(F) for requirements.
c) Child Abuse Assessment 7 hours Must include detailed knowledge of the California Child
and Reporting in California Abuse Neglect and Reporting Act (CANRA). It must also
include assessment and methods of reporting of sexual
assault, neglect, severe neglect, general neglect, willful
cruelty or unjustifiable punishment, corporal punishment or
injury, and abuse in out-of-home care. The training shall
also include physical and behavioral indicators of abuse,
crisis counseling techniques, community resources, rights
and responsibilities of reporting, consequences of failure to
report, caring for a child’s needs after a report is made,
sensitivity to previously abused children and adults, and
implications and methods of treatment for children and
adults. See
BPC sections 28 and 4996.17.2 and Title 16,
California Code of Regulations (1
6CCR) section 1807.2.
d) Human Sexuality 10 hours Must include the study of the physiological, psychological,
and social cultural variables associated with sexual
behavior, gender identity, and the assessment and
treatment of psychosexual dysfunction. See
BPC sections
25 and 4996.17.2 and 16C
CR section 1807.
e) Alcoholism / Other
Chemical Substance
Dependency
15 hours See BPC section 4996.17.2 and 16CCR section 1810
.
f) Spousal or Partner Abuse
Assessment, Detection and
Intervention
15 hours
Must cover spousal o
r partner abuse assessment, detection
and intervention strategies. See BPC section 4996.17.2.
g) Aging, Long Term Care and
Elder/Dependent Adult
Abuse
10 hours Must cover aging and long-term care, biological, social,
psychological aspects of aging, and instruction on the
assessment and reporting of, as well as treatment related to,
elder and dependent adult abuse and neglect. See
BPC
sections 4996.17.2 and 4996.25.
h) California Cultures and the
Social and Psychological
Implications of
Socioeconomic Position
15 hours or
1 semester
unit
Must include an understanding of various California cultures
and the social and psychological implications of
socioeconomic position. See BPC section 4996.17.2
.
5
BBS
Board
of
Behavioral
Sciences
APPLICATION FOR LICENSURE
LICENSED CLINICAL
SOCIAL WORKER
Out-of-State Applicant
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
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-531 (Revised 01/2021) 1
REQUIREMENTS FOR ALL APPLICANTS
A. GENERAL APPLICATION
Instructions Document(s) Required
• Complete all sections of the Application for Licensure – General
Application 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
General Application
37A-531 (Revised 01/2021) 2
REQUIREMENTS FOR ALL APPLICANTS (CONTINUED)
B. FEES
Instructions Document(s) Required
Carefully read the information below to determine the fees and
possible additional forms required. Incorrect submission will delay
your application.
If you need clarification, contact bbs.lcsw@dca.ca.gov prior to
submission.
1. Out-of-state applicants who have NEVER been issued a
registration or license with the BBS:
Attach a $400.00 check or money order to your Application for Licensure
– General Application, made payable to the Behavioral Sciences Fund.
The $400.00 fee consists of a $250.00 application fee and a $150.00
California Law and Ethics Exam fee. The application fee is an earned fee
for evaluation of your application and is NOT REFUNDABLE.
2. Out-of-state applicants who HAVE been issued a registration or
license with the BBS at any time in the past:
a. If you have NOT yet passed the California Law and Ethics Exam, you
must submit BOTH of the following (i & ii below). Provide SEPARATE
checks or money orders:
i. Attach a $250.00 check or money order to your Application for
Licensure - General Application, made payable to the Behavioral
Sciences Fund. This is an earned fee for the evaluation of your
application and is NOT REFUNDABLE.
*AND*
ii. Submit one of the following:
o If you have never taken the California Law & Ethics Exam:
Attach a $150.00 check or money order to a Registrant
Request for Initial California Law and Ethics Examination.
o If you have taken, but not yet passed the California Law &
Ethics Exam:
Attach a $150.00 check or money order to an Application for
Re-Examination.
b. If you HAVE passed
the California Law and Ethics Exam, simply attach
a $250.00 check or money order to your Application for Licensure -
General Application, made payable to the Behavioral Sciences Fund.
This is an earned fee for the evaluation of your application and is
NOT REFUNDABLE.
1. A $400.00 check or
money order
payable to the
Behavioral Sciences
Fund attached to
your General
Application
2.a. Both of the
following, payable
to the Behavioral
Sciences Fund:
• A $250 check or
money order
attached to your
General
Application
AND
• A $150 check or
money order
attached to an
Exam
Application
2.b. A $250 check or
money order
payable to the
Behavioral
Sciences Fund,
attached to your
General Application
37A-531 (Revised 01/2021) 3
REQUIREMENTS FOR ALL APPLICANTS (CONTINUED)
C. FINGERPRINTS
Instructions Document(s) Required
Disregard this section if you are currently registered with the BBS
as an Associate
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.
• The information on this form must match the information you
provide on your application.
• DO NOT COMPLETE FINGERPRINTS MORE THAN 60 DAYS
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.
• 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.
• Note: The DOJ processing time for hard card fingerprints is a
minimum of 8 weeks.
If you currently reside
in California: Submit
the second copy of
your completed
Request for Live Scan
Service Applicant
Submission form.
If you currently reside
out of state:
Submit two completed
fingerprint hard cards
(FBI and DOJ).
D. VERIFICATION OF LICENSURE/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
37A-531 (Revised 01/2021) 4
LICENSURE PATHWAY REQUIREMENTS
This section will help you determine your specific application,
education, experience and examination requirements.
Path A – LICENSURE BY CREDENTIAL
You may qualify for Path A if you meet ALL of the following requirements:
I have held a license as a Clinical Social Worker in another United States jurisdiction for at
least two years.
The license I hold is current, and has been active and unrestricted for at least two years
immediately before the date I submit my application to the Board.
The license I hold is at the highest level for independent clinical practice in that jurisdiction.
The degree that qualified me for this license is a master’s degree obtained from a school or
department of social work that is accredited by the Council on Social Work Education.
If you do NOT meet ALL of the above requirements:
You do NOT qualify for LICENSURE BY CREDENTIAL
Skip to Path B:
LICENSURE BY EDUCATION AND EXPERIENCE (Page 6)
If you DO meet ALL of the above requirements:
You must comply with Path A:
LICENSURE BY CREDENTIAL
37A-531 (Revised 01/2021) 5
Path A – LICENSURE BY CREDENTIAL
1. APPLICATION FOR PATH A
Instructions Document(s) Required
Submit Application for Path A - Licensure by Credential. Must have an
original signature.
Application for Path A
2. CALIFORNIA LAW AND ETHICS EXAMINATION
Instructions Document(s) Required
You must pass the California Law and Ethics Examination. You will be
eligible to take this exam after your application has been approved. You
will be provided with information on how to register at that time.
None at this time
3. QUALIFYING DEGREE
Instructions Document(s) Required
Provide official transcript(s) verifying your qualifying master’s degree with
degree title and date of conferral posted as directed below:
• Mailed to the Board IN AN ENVELOPE SEALED BY THE
EDUCATIONAL INSTITUTION; or
• Sent electronically BY YOUR SCHOOL to the Board at
BBSLCSWtranscripts@dca.ca.gov (for questions about electronic
submission, see FAQ).
Note: The degree that qualified you for licensure in another United
States jurisdiction must be a master’s degree obtained from a school or
department of social work that is accredited by the Council on Social
Work Education Otherwise, you must apply under “Licensure by
Education and Experience” (See Path B).
Official transcript(s)
with degree title and
date of conferral posted.
MUST BE SENT
ELECTRONICALLY BY
SCHOOL OR MAILED IN
A SEALED ENVELOPE
AS DIRECTED
4. COURSEWORK
Instructions Document(s) Required
You must complete the California-specific coursework listed in Path A
of the Guide to LCSW Out-of-State Applicant Requirements.
Proof of completion of
all required courses
5. 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 the Law
and Ethics Exam, submit
a Request for Initial
License Issuance and fee
37A-531 (Revised 01/2021) 6
Path B – LICENSURE BY EDUCATION AND EXPERIENCE
Applicants who do not qualify for LICENSURE BY CREDENTIAL must meet ALL
of the following requirements in order to become licensed in California:
1. APPL
ICATION FOR PATH
B
Instructions Document(s) Required
Submit Application for Path B - Licensure by Education and
Experience. Must have an original signature.
Application for Path B
2. EXAMINATIONS
Instructions Document(s) Required
You must pass the California Law and Ethics Examination 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.
If you already took the ASWB Clinical Exam for another state, the
Board may accept your passing score as follows:
• If you do not currently hold a license or registration in another state
or country your passing score must be less than seven (7) years
old;
• If you currently hold a license or registration in another state or
country and the license or registration is active and in good
standing at the time of application and is not revoked, suspended,
surrendered, denied or otherwise restricted or encumbered, a
passing score of any age will be accepted;
You must provide the Board with official proof to verify your passing
score. Download an Official Score Transfer Request form from the
Association of Social Work Boards’ website. Your score verification
must arrive in an envelope that has been SEALED by the ASWB.
ASWB Clinical Exam
Score Verification (if
applicable) SEALED
by the ASWB
37A-531 (Revised 01/2021) 7
Path B – LICENSURE BY EDUCATION AND EXPERIENCE
3. SUPERVISED EXPERIENCE
Determine Your Requirements Requirement
I am licensed as an LCSW at the highest level for independent clinical
practice in another state or country that requires at least 3,000 hours of
supervised experience OR
I am licensed in another state or country that requires less than 3,000
hours of supervised experience and I am making up the deficit using time
licensed as an LCSW at the highest level for independent clinical practice
(maximum 1,200 hours).
You are not required to
provide verification of
experience. Skip to # 4
(Degree Requirements).
I am licensed in another state or country that requires less than 3,000 You must provide
hours of supervised experience and I am making up the deficit using time verification of
licensed as an LCSW at the highest level for independent clinical practice, experience to reach a
but it is not enough to total 3,000 hours OR total of 3,000 hours.
I am not licensed in another state or country at the highest level for
independent clinical practice.
Your specific
requirements are
described below.
Instructions for Applicants Who Must Submit Verification of Experience Document(s) Required
You must submit verification of substantially equivalent supervised experience
totaling 3,000 hours as described below:
• Experience must have been supervised by a licensed mental health
professional and gained within the six (6) years prior to the Board’s receipt
of your California application.
• Any hours gained in California must be while registered as an Associate.
• If you are not licensed in another state or country at the highest level for
independent clinical practice, you must have 104 weeks of supervision.
Experience Gained OUTSIDE of California:
• Submit an original Out-of-State Experience Verification form completed by
each supervisor. Use separate Out-of-State Experience Verification forms
for each supervisor and each employer.
• Each supervisor’s license must be verified using one of the methods
below. A Verification of Licensure in Another State form is included for this
purpose.
o Emailed to the Board directly from the other state to
BBSLicCerts@dca.ca.gov
Original Out-of-State
Experience
Verification form(s)
Verification(s) of
supervisor’s license
emailed or sent to the
Board in a SEALED
ENVELOPE OR
EMAILED AS
o Sent to the Board directly from the other state IN AN ENVELOPE
SEALED BY THE STATE LICENSING AGENCY.
o Enclosed with the application IN AN ENVELOPE SEALED BY THE
STATE LICENSING AGENCY.
DIRECTED
37A-531 (Revised 01/2021) 8
Path B – LICENSURE BY EDUCATION AND EXPERIENCE
3. SUPERVISED EXPERIENCE (continued)
Instructions for Applicants Who Must Submit Verification of Experience Document(s) Required
Experience Gained WITHIN California:
Original In-State
EXPERIENCE VERIFICATION: Use the In-State Experience Verification
Experience
form, available on the Board’s website. Must contain an original signature.
Verification form(s)
Use separate In-State Experience Verification forms for each supervisor and
each employer. Do not submit Weekly Log forms unless requested.
Copies of W-2
W-2 FORMS: If you were employed while gaining hours, you must submit
Form(s)/Check stub
copies of your W-2 for each year you are claiming, and for each employer. If
for current year (if
your W-2 is not available, you may submit a copy of your “Wage and
applicable)
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 does not match the name of your employer listed on the experience
verification form, an explanation is required. If you are submitting a 1099, an
explanation is required.
Original Volunteer
VOLUNTEER LETTER: If you volunteered while gaining hours, a letter from
Letter(s) (if
your employer is required indicating your voluntary status on your
applicable)
employer’s letterhead. A sample letter is available on the Board’s website.
The letter must state the time frame (date range) during which you
volunteered and contain an original signature.
Original Supervisor
SUPERVISOR RESPONSIBILITY STATEMENT: Submit a Responsibility
Responsibility
Statement for each supervisor. Must contain an original signature.
Statement(s)
Original Supervisory
SUPERVISORY PLAN: Submit a Supervisory Plan for each supervisor and
Plan(s)
each employer. Must contain an original signature.
Original signed/dated
LETTER OF AGREEMENT: Submit a copy of the written oversight
letter(s) of agreement
agreement for each supervisor and each employer, if applicable. See BPC
(if applicable)
section 4996.23.3. Must contain original signatures.
37A-531 (Revised 01/2021) 9
Path B – LICENSURE BY EDUCATION AND EXPERIENCE
4. DEGREE REQUIREMENTS
Instructions Document(s) Required
Disregard this section if you are currently registered with the BBS as an
Associate
You must possess a master’s degree obtained from a school or
department of social work that is accredited by the Council on Social
Work Education (CSWE). See # 5 for requirements if your degree was
obtained outside the U.S. Submit official transcripts with degree title and
date of conferral posted in an envelope sealed by the school.
Official transcript(s)
showing degree title
and date of conferral.
MUST BE IN A
SEALED ENVELOPE
5. DEGREE OBTAINED OUTSIDE THE U.S.
Instructions Document(s) Required
Disregard this section if you are currently registered with the BBS as an
Associate
If your degree was earned from a school outside the U.S., you must
obtain a comprehensive evaluation of your degree in order to determine
equivalency to a master's from a program accredited by the CSWE.
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 #4 above.
Degree evaluation by
a foreign credential
evaluation service (if
applicable). MUST BE
IN A SEALED
ENVELOPE
6. CALIFORNIA LAW AND ETHICS COURSE
Instructions Document(s) Required
Disregard this section if you are currently registered with the BBS as an
Associate
You are required to complete a 12-hour course in California Law and
Ethics. The course may be taken from a school or department of social
work that is accredited by the CSWE, a school that holds a regional or
national institutional accreditation recognized by the USDE, a school
approved by the BPPE, or an acceptable continuing education
provider.
Proof of completion of
California Law and
Ethics course
37A-531 (Revised 01/2021) 10
Path B – LICENSURE BY EDUCATION AND EXPERIENCE
7. ADDITIONAL COURSEWORK
Instructions Document(s) Required
You must complete the California-specific coursework listed in Path B
of the Guide to LCSW Out-of-State Applicant Requirements.
If you submitted documentation of completion with a prior application, it
is not necessary for you to resubmit this information.
Proof of completion of
Additional Coursework
8. 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-531 (Revised 01/2021) 11
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
Out-of-State Applicant
GENERAL APPLICATION
To Be Completed by All Out-Of-State Applicants
Office Use Only:
Carefully read the Application Instructions FIRST
BBS
Board
of
Behavioral
Sciences
FEE: Attach a fee in the amount specified in the Application Instructions.
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
* 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-203 (Revised 01/2021) Page 1 of 3
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Applicant Name: Last First Middle
1. Have you ever served in the United States Armed Forces or the
Yes, Currently No
California National Guard? (OPTIONAL)
Yes, Previousl
2. 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):
y
State
Type of License, Registration
or Certificate
License, Registration
or Certificate Number
Date
Issued
Status
3. 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.
4. If you hold or have held a license or registration to practice clinical social Yes No
work outside of California, have you attached a Verification of License or
N/A
Registration form for each license or registration held?
5. I am applying for: Licensure by Credential: I have attached the Application for Path A
Licensure by Education and Experience: I have attached the Application
for Path B.
37A-203 (Revised 01/2021) Page 2 of 3
Applicant Name: Last First Middle
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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-203 (Revised 01/2021) Page 3 of 3
Applicant Name: Last First Middle
BBS
Board
of
Behavioral
Sciences
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APPLICATION FOR LICENSURE
LICENSED CLINICAL
SOCIAL WORKER
Out-of-State Applicant
APPLICATION FOR PATH A.
LICENSURE BY CREDENTIAL
This form must be accompanied by a General Application
1. QUALIFICATIONS:
A. I have held a license as a Clinical Social Worker in another United States
jurisdiction for at least two years.
B. The license I hold is current, and has been active and unrestricted for at
least two years immediately before the date I submit my application to the
Board.
C. The license I hold is at the highest level for independent clinical practice in
that jurisdiction.
D. The degree that qualified me for this license is a master’s degree obtained
from a school or department of social work that is accredited by the Council
on Social Work Education.
Yes No
Yes No
Yes No
Yes No
If you answered NO to any of the above, you must instead apply using the Application
for Path B - Licensure by Education and Experience.
2. OFFICIAL TRANSCRIPTS:
Yes – Sealed Transcripts via Mail
Have you submitted official sealed transcripts verifying
your qualifying master’s degree as described in 1.D.
Yes – Electronic Transcripts
above? See Application Instructions for requirements.
No
37A-203A (Revised 01/2021) Page 1 of 2
Applicant Name: Last First Middle
3. CALIFORNIA-SPECIFIC COURSEWORK:
List the course providers below and attach documentation of completion for each course. See
Application Instructions for course content and provider requirements.
a) California Law and Ethics (12 hours)
Provider Name:
b) Child Abuse Assessment and Reporting in California (7 hours)
Provider Name:
c) California Cultures and the Social and Psychological Implications of Socioeconomic Position
(15 hours)
Provider Name:
d) Suicide Risk Assessment and Intervention (6 hours)
Provider Name:
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-203A (Revised 01/2021) Page 2 of 2
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Board
of
Behavioral
Sciences
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APPLICATION FOR LICENSURE
LICENSED CLINICAL
SOCIAL WORKER
Out-of-State Applicant
APPLICATION FOR PATH B.
LICENSURE BY EDUCATION AND EXPERIENCE
This form must be accompanied by a General Application
Applicant Name: Last First Middle
1. CLINICAL EXAMINATION
If you have passed the Association of Social Work Boards Clinical Exam,
have you requested an official sealed score report?
Yes
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N/A
No
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2. EXPERIENCE
Are you required to submit supervised experience hours?
(see Application Instructions to determine)
Yes No
If YES, have you attached the required verification of experience?
Yes No
3. OFFICIAL TRANSCRIPTS
Have you submitted official sealed transcripts verifying your
qualifying master’s degree? See Application Instructions for
requirements.
4. CALIFORNIA LAW AND ETHICS COURSE (12 hours)
Have you attached documentation of completion of the
required 12-hour course in California Law and Ethics as
described in the Application Instructions?
Yes – Sealed Transcripts via Mai
Yes – Electronic Transcripts
No
Yes No
Previously Submitted
37A-203B (Revised 07/2020) Page 1 of 2
Applicant Name: Last First Middle
5. ADDITIONAL COURSEWORK
List the titles of the courses you have completed and the course providers below.
See Guide to Out-of-State Applicant Requirements for information on course content and provider
requirements. You must submit documentation of completion unless previously submitted.
a) Child Abuse Assessment and Reporting in California (7 hours)
Course Title(s):
Provider(s):
b) Human Sexuality (10 hours)
Course Title(s):
Provider(s):
c) Alcoholism and Other Chemical Substance Dependency (15 hours)
Course Title(s):
Provider(s):
d) Spousal or Partner Abuse Assessment, Detection and Intervention (15 hours)
Course Title(s):
Provider(s):
e) Aging, Long Term Care; Elder/Dependent Adult Abuse (10 hours)
Course Title(s):
Provider(s):
f) California Cultures, and the Social and Psychological Implications of Socioeconomic Position
(15 hours)
Course Title(s):
Provider(s):
g) Suicide Risk Assessment and Intervention (6 hours)
Course Title(s):
Provider(s):
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-203B (Revised 01/2021) Page 2 of 2
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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/licensi0ng 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)
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BBS
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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
OUT OF STATE EXPERIENCE VERIFICATION
Have your out-of-state supervisor complete this form as follows:
o Use a separate form for each supervisor and
o Provide an original signature in ink and
employer have the signer initial any changes
o Make sure this form is complete and correct o Submit with your Application for Licensure
prior to signing
APPLICANT NAME: ______________________________________
APPLICANT’S EMPLOYER INFORMATION
Applicant’s Employer’s Name:
Telephone
Address: Number and Street
City
State
Zip Code
SUPERVISOR INFORMATION
Supervisor’s Name
Telephone
Email Address (OPTIONAL)
License Type
License Number
State
Date First Licensed
Physicians: Were you certified in Psychiatry by the American Board of Psychiatry and Neurology during
the entire period of supervision? Yes No
If YES, provide certificate number:_________________
37A-202 (Revised 01/2019) 1 of 2
APPLICANT NAME: _______________________________________
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. 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.
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-202 (Revised 01/2019) 2 of 2
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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)
Marriage and Family Therapist
Educational Psychologist
Clinical Social Worker
Professional Clinical Counselor
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 License: (Mark Only ONE)
Type of Application: LIC/PERMIT/CERT
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)
Marriage and Family Therapist
Educational Psychologist
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 License: (Mark Only ONE)
Type of Application: LIC/PERMIT/CERT
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)
Marriage and Family Therapist
Clinical Social Worker
Professional Clinical Counselor
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 License: (Mark Only ONE)
Educational Psychologist
Type of Application: LIC/PERMIT/CERT
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)
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BBS LICENSED CLINICAL SOCIAL WORKER APPLICATION FOR LICENSURE (California)

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Completed 16 April 2021

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