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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
ASSOCIATE CLINICAL SOCIAL WORKER
WEEKLY TRACKING LOG
This form is only for the purposes of tracking supervised work experience and is not official documentation.
Experience must be submitted on the Experience Verification form when you apply for licensure. Note: The
letters “A,” “A1,” “B,” and “C” correspond directly to the lettering system used on the Experience Verification
form.
Use a separate log for each work setting.
Indicate your status when the hours below are logged:
Associate Application Pending
BBS File No. (if known): _______________
Registered Associate - ASW No.: _______________
YEAR:_______
Supervision, Individual or Triadic*
A.
Clinical Psychosocial
Diagnosis, Assessment, and
Treatment,
including
Individual or Group
Psychotherapy or Counseling
A1.
Individual or Group
Psychotherapy
**
B.
-
centered advocacy,
consultation, evalua
tion,
research, workshops,
seminars, training sessions or
conferences, and direct
supervisor contact
C.
Total Hours Per Week
(A + B = C)
Maximum 40 hours/week
Week of:
Week of:
Week of:
Week of:
Week of:
* 104 supervised weeks are required for licensure.
** Line A1 is a sub-category of line “A.” This line tells you how much of “A” was Individual or Group
Psychotherapy. When totaling hours of experience do not double count these hours. Use the formula found
in box “C” to total your hours of supervised experience for the week.
37A-209 (Revised 01/2021)
