Fillable Lcsw2 LCSW 2 (New York State Education Department)

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Lcsw2 LCSW 2 (New York State Education Department)

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The University of the State of New York
The State Education Department
Office of the Professions
Division of Professional Licensing Services
www.op.nysed.gov
Licensed Clinical Social Worker Form 2
Certification of Professional Education
Applicant Instructions
1. Complete Section I. In item 3, enter your name exactly as it appears on your Application for Licensure (Form 1). Be sure to sign and
date item 9.
2. Send the entire form to the institution(s) you attended and ask the registrar to complete Section II and forward all pages of the form
directly to the Office of the Professions at the address at the end of this form. Be sure to include any fee required by the institution.
This form will not be accepted if submitted by the applicant.
3. An official transcript or marksheets are required if you completed a program that is not registered by the Department as licensure
qualifying at the time of your graduation.
Section I - Applicant Information
1. Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
2. Birth Date
Month Day Year
3. Print Your Name Exactly As It Appears On Your Application for Licensure (Form 1)
Last
First
Middle
4. Mailing Address (You must notify the Department promptly of any address or name changes)
Line 1
Line 2
Line 3
City
State ZIP Code
Country/
Province
5. Name as it appears on your degree or diploma
6. Institution attended
Name
City, State or Country
7. Name of degree/diploma
8. Date degree/diploma awarded
mo. day yr.
9. I request and give my permission to the institution listed in item 6 above to complete Section II of this form and mail it to the New York
State Education Department at the address at the end of this form, and to release any other information requested by the State Education
Department in connection with my application for licensure.
Applicant's Signature Date
Licensed Clinical Social Worker Form 2, Page 1 of 3, Revised 4/18
Section II - Certification of Professional Education
Instructions to Registrar: Complete Part A or Part B to document the applicant's education. Complete Part C (Certification) and return the
entire form directly to the Office of the Professions at the address at the end of this form. This form will not be accepted if submitted by the
applicant.
Name of the applicant
(see Section I, item 5)
Part A - Completion of Education Requirement
The applicant completed a master of social work program that was, at the time the degree requirements were met, registered as licensure-
qualifying by the New York State Education Department for the Licensed Clinical Social Worker.
It is certified that the applicant:
completed the program on
mo. day yr.
State Education Department Program Code
and was awarded the degree/diploma of:
(Title of degree/diploma)
on
mo. day yr.
Part B - Please complete this part for programs not registered as licensure-qualifying by the New York State Education Department
for Licensed Clinical Social Worker at the time the applicant completed the program. An official transcript or marksheet giving
courses completed by year and grades and a syllabus on the course of studies completed must be attached.
1. Date of applicant's entrance, and either the applicant's date of completion of studies or withdrawal from the school
Entrance Date
mo. day yr.
Completion Date
mo. day yr.
Withdrawal Date
mo. day yr.
2. Did the applicant complete a field practicum of at least 900 clock hours? (check one)
Yes No
If "no", number of clock hours completed
3. Degree/diploma conferred
Date degree/diploma conferred
mo. day yr.
Name of the accrediting body or official organization that recognizes this program
Address of the accrediting body or official organization that recognizes this program
Licensed Clinical Social Worker Form 2, Page 2 of 3, Revised 4/18
Section II - Certification of Professional Education (Continued)
Part B (continued) - List the courses that were completed in the M.S.W. program that meet the requirement for at least 12 semester
hours, or the equivalent, of clinical coursework that prepares the applicant to practice as a licensed clinical social worker. The
courses must be included on the official transcript provided by the graduate social work program.
Required Content Area Course Number, Title and Semester Hours
Diagnosis and assessment in clinical
social work process
Clinical social work treatment
Clinical social work practice with
general and special populations
Part C - Certification. This form will not be accepted if the date below precedes the date in either Part A or Part B.
I hereby certify that to the best of my knowledge and belief the information in Section II is a true statement of the record of the educational
record of the individual named on this form.
Signature of Registrar Date
Print Name
Title or official position
Institution
Address
Telephone Fax
Email
Seal
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Social Work
Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Licensed Clinical Social Worker Form 2, Page 3 of 3, Revised 4/18
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Completed 22 July 2020

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