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COMMONWEALTH OF VIRGINIA (Virginia Department of Motor Vehicles)

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Revised 08/2016 – Paper Application for LCSW by Endorsement 1
COMMONWEALTH OF VIRGINIA
BOARD OF SOCIAL WORK
Department of Health Professions
9960 Mayland Drive, Suite 300
Henrico, Virginia 23233-1463
(804) 367-4441
Website - http://www.dhp.virginia.gov/social
PAPER APPLICATION INSTRUCTIONS FOR LICENSURE AS A
CLINICAL SOCIAL WORKER (LCSW) BY ENDORSEMENT
Application:
Upon completion of the LCSW by Endorsement application you will be required to submit to the Board office the following
items:
Fee: A $165.00 application fee must be paid by check or money order made payable to the “Treasurer of Virginia”.
This fee is non-refundable. The application can be used for one year from date of receipt.
Out-of-State Licensure Verification: If you have ever held any other health or mental health licensure and/or
certification, please send the enclosed verification form to the issuing jurisdiction. This verification is to be
completed by the issuing jurisdiction and should be included in your application packet. Verifications older than six
month will not be accepted.
Online verifications will be accepted; however online verifications must include the name of licensee, title of
license, license number, issue and expiration date, and if there is any public information related to the
license/certificate.
Clinical Scores: If you have passed the ASWB clinical exam in another state, please request the official score
report from the Association of Social Work Boards (“ASWB”) by calling (800) 225-6880. Your exam scores will
be sent directly from the ASWB to the Virginia Board of Social Work electronically.
Note: If you have not passed the ASWB clinical exam, Virginia can grant approval to take the examination.
You will be subject to the requirements outlined in 18 VAC 140-20-70 of the Regulations Governing the
Practice of Social Work.
Verification of Post-Licensure Active Practice/Supervision Experience:
To validate your active post-licensure practice as an independent clinical social worker, you must submit the
Post-Licensure Active Practice form completed by your employer, a colleague, peer or a licensed practitioner
who can attest to your post-licensure active practice in clinical social work for 24 of the last 60 months. If you
have had several jobs, please submit multiple verification forms equaling to a minimum of 24 months.
OR
In lieu of the active practice form listed above, you must provide evidence of supervised experience
requirements substantially equivalent to those outlined in 18VAC140-20-50. You can provide any of the
following documentation if you do not have 24 out of the past 60 months:
o Verification of Clinical Supervision Form (can be found within the supporting documentation below);
or
o Supervision Verification from the original state in which you received your clinical license, which can
be provided by submitting a copy of your licensure file which contains your original supervision
documentation.
Name Change: Documentation must be provided if your name has legally changed through marriage, divorce, or a
court order. A photocopy of your marriage license or a copy of the court order must be provided.
NPDB Self-Query: a current report from the U.S. Department of Health and Human Services National Practitioners
Data Bank (NPDB) must be submitted. You may request a self-query at https://www.npdb.hrsa.gov/.
Revised 08/2016 – Paper Application for LCSW by Endorsement 2
COMMONWEALTH OF VIRGINIA
BOARD OF SOCIAL WORK
Department of Health Professions
9960 Mayland Drive, Suite 300
Henrico, Virginia 23233-1463
(804) 367-4441
Website - http://www.dhp.virginia.gov/social
APPLICATION FOR LICENSURE AS A CLINICAL SOCIAL WORKER (LCSW)
BY ENDORSEMENT
INSTRUCTIONS PLEASE TYPE OR PRINT
CLEARLY
USE BLUE OR BLACK INK
Applicant must complete all sections.
GENERAL INFORMATION
Name of Applicant (Last, First) Middle Initial
Maiden Name*
Suffix
Social Security Number or Virginia DMV Control Number**
Date of Birth (MM/DD/YY)
Mailing Address (Street and/or Box Number, City, State, Zip Code)
Home Telephone Number
Public Address (Street and/or Box Number, City, State, Zip Code)***
Alternate Telephone Number
E-mail Address
Are you the spouse of a member of the U. S. military who has been transferred to Virginia and did you leave employment to
accompany your spouse to Virginia?
Yes No
Can you provide verification of a passing score on the ASWB clinical examination? Yes No
LICENSURE/CERTIFICATION – List in order of attainment all the states in which you now hold or have ever held an
occupational license or certificate to practice as a social worker in order of attainment.
STATE
LICENSE/CERTIFICATE
NUMBER
ISSUE DATE
TYPE OF
LICENSE/CERTIFICATE
**In accordance with § 54.1-116 of the Code of Virginia, you are required to submit your Social Security Number or your control number issued by the
Virginia Department of Motor Vehicles.
***Licensure Address is Public Information and Published on the Internet.
Revised 08/2016 – Paper Application for LCSW by Endorsement 3
ANSWER THE FOLLOWING QUESTIONS:
1. Have you ever been denied the privilege of taking an occupational licensure or certification
examination?
If yes, state what type of occupational examination and where:
Yes No
2. Have you ever had any disciplinary action taken against an occupational license to practice or are
any such actions pending?
If yes, explain in detail on a separate sheet of paper.
Yes No
3. Have you ever been convicted of a violation of or pled nolo contendere to any federal, state, or
local statute, regulation or ordinance or entered into any plea bargaining relating to a felony or
misdemeanor? (Excluding traffic violations and driving under the influence.)
If yes, explain in detail on a separate sheet of paper and provide court documents.
Yes No
4. In the last twelve (12) months, have you been unable to practice social work by reason of
excessive use of alcohol, drugs, chemicals or any other type of material or as a result of any mental
or physical condition? If yes, please provide an explanation on a separate sheet of paper.
Yes No
5. Have you ever been censored, warned, or requested to withdraw from your employment,
terminated from any health care facility, agency, or practice? If yes, provide an explanation on a
separate sheet of paper.
Yes No
6. Are you the respondent in any pending or unresolved board action in another jurisdiction or in a
malpractice claim?
Yes No
The following statement must be executed by a Notary Public. This form is not valid unless properly notarized.
AFFIDAVIT
(To be completed before a notary public)
State of _________________________ County/City of _________________________
Name __________________________________________________, being duly sworn, says that he/she is the person who is referred
to in the foregoing application for licensure as a clinical social worker in the Commonwealth of Virginia; that the statements herein
contained are true in every respect, that he/she has complied with all requirements of the law; and that he/she has read and
understands this affidavit.
________________________________________
Signature of Applicant
Subscribed to and sworn to before me this _______________ day of ____________________, 20____________________.
________________________________________
Signature of Notary Public
My commission expires _______________ day of ____________________, 20____________________.
SEAL
Revised 08/2016 – Paper Application for LCSW by Endorsement 4
COMMONWEALTH OF VIRGINIA
BOARD OF SOCIAL WORK
Department of Health Professions
9960 Mayland Drive, Suite 300
Henrico, Virginia 23233-1463
(804) 367-4441
Website: http://www.dhp.virginia.gov/social
APPLICANT OUT-OF-STATE LICENSURE VERIFICATION
To be completed by applicant:
Last Name _______________________________________ First Name ___________________________________ M.I. _______
Address __________________________________________________________________________________________________
City _____________________________________________ State ___________________________ Zip Code ________________
Home Phone Number _______________________________ Work Number ____________________________________________
Email Address _____________________________________________________________________________________________
To be completed by state Board of Social Work:
Title of License ___________________________________________ License Number ____________________________________
Issue Date _______________________________________________ Expiration Date _____________________________________
By Examination By Waiver By Endorsement Reciprocity
Is there any public information relating to this license?
Yes (specify details on a separate sheet) No
Certification by the authorized Licensure Official of the State of ____________________________________________________
I certify that the information is correct.
Authorized Licensure Official Name and Title __________________________________________________________________
State Seal
Title of Board ______________________________________
Telephone Number __________________________________
Email Address ______________________________________
Date ______________________________________________
Revised 08/2016 – Paper Application for LCSW by Endorsement 5
COMMONWEALTH OF VIRGINIA
BOARD OF SOCIAL WORK
Department of Health Professions
9960 Mayland Drive, Suite 300
Henrico, Virginia 23233-1463
(804) 367-4441
Website: http://www.dhp.virginia.gov/social
VERIFICATION OF POST-LICENSURE ACTIVE PRACTICE
AS A CLINICAL SOCIAL WORKER
To be completed by applicant:
I, __________________________________________________, hereby authorize past and present employers, businesses,
(Printed Name of Applicant)
professional associates and personal references to release to the Virginia Board of Social Work (“Board”) any information
requested by the Board in connection with the processing of my application.
________________________________________
Signature of Applicant
To be completed by reference:
Name of Reference: _______________________________ Type of License Held: __________________________________
Mailing Address of Reference (Street, and/or Box Number, City, State, Zip Code):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Relationship to Applicant:
__________________________________________________________________________________
I, __________________________________________________, declare under perjury under the laws of the
(Printed Name of Reference)
Commonwealth of Virginia that __________________________________________________, candidate for
(Printed Name of Applicant)
Licensed Clinical Social Worker licensure in the Commonwealth of Virginia was in active post-licensure clinical practice at
____________________________________________________________________________________________________
____________________________________________________________________________________________________
(Location Name and Address)
from ______________________________________________ to _____________________________________________.
(MM/DD/YY) (MM/DD/YY)
__________________________________________________ _________________________________________
Signature of Reference Date
Revised 08/2016 – Paper Application for LCSW by Endorsement 6
COMMONWEALTH OF VIRGINIA
VIRGINIA BOARD OF SOCIAL WORK
Department of Health Professions
9960 Mayland Drive, Suite 300
Henrico, Virginia 23233-1463
(804) 367-4441
Website - http://www.dhp.virginia.gov/social
VERIFICATION OF CLINICAL SUPERVISION
I. GENERAL INFORMATION PLEASE TYPE OR PRINT CLEARLY USE BLUE OR BLACK INK
Name of Applicant (Last, First) Applicants Email Address
II. SUPERVISOR’S EVALUATION: ANSWERS SHOULD BE PROVIDED BASED ON THE SUPERVISION OBTAINED UNDER THE
INSTRUCTION OF THE SUPERVISOR COMPLETING THE FORM.
Supervisor’s Name (Last, First) Supervisor’s Telephone Number
Business Name and Address of Supervision Work Site (ONE LOCATION ONLY)
Dates of supervision: From: ____________________ to ____________________
Did the applicant receive a minimum of one (1) hour and a maximum of four (4) hours of face-to-
face supervision per 40 hours of work experience for a total of at least 100 hours with no more
than 50 of the 100 hours obtained in group supervision?
Yes No
If not, how many? ____________
Did applicant complete a minimum of 3,000 hours of supervised post-master's degree experience
in the delivery of “clinical social work services” and in ancillary services that support such
delivery?
Yes No
If not, how many? ____________
Did the applicant obtain throughout their hours of supervision a minimum of 1,380 hours of
supervised experience in face-to-face client contact in the delivery of “clinical social work services”
while under your direct supervision?
Yes No
If not, how many? ____________
Did the applicant demonstrate minimum competencies of identified theory base?
Yes No
Did the applicant demonstrate minimum competencies of application of a differential diagnosis?
Yes No
Did the applicant demonstrate minimum competencies of establishing and monitoring a treatment
plan?
Yes No
Did the applicant demonstrate minimum competencies of development and appropriate use of the
professional relationship?
Yes No
Did the applicant demonstrate minimum competencies of assessing the client for risk of imminent
danger?
Yes No
Did the applicant demonstrate minimum competencies of implementing a professional and ethical
relationship with clients?
Yes No
Did the applicant demonstrate minimum competencies of understanding the requirements of law
for reporting any harm or risk of harm to self or others?
Yes No
In your opinion has the applicant demonstrated competency sufficient for licensing and the
independent practice as a clinical social worker?
Yes No
I declare that, to the best of my knowledge, the foregoing is true and correct.
__________________________________________ __________________________________
Supervisor's Signature Date
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Completed 9 June 2021

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