Fillable Lcsw4b Licensed Clinical Social Worker 4B

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Lcsw4b Licensed Clinical Social Worker 4B

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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 4B
Certification of Experience for
Licensed Clinical Social Worker
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 8. Use
the psychotherapy log to document your hours of practice and supervision. This log must be completed by you and your supervisor. All pages of the
log must be retained by the supervisor, in the event the State Board requests clarification.
2. Send the entire form along with a copy of Appendix A to your supervisor (if your supervisor is unavailable, you must provide the supervisor's
qualifications and your experience may be verified by a licensed colleague) and ask him/her to complete Section II and forward the entire form directly
to the Office of the Professions at the address at the end of the form. This form will not be accepted if submitted by the applicant. Note: If the
experience being certified on this form was completed outside New York State, you must also have a Form 4Q submitted by this supervisor.
Applicant Instructions
Assigned Number (from Form 4):
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. Telephone/Email Address
Daytime Phone
Area Code Phone
Email Address (please print clearly)
6. New York State LMSW license number
M.S.W. degree date
mo. day yr.
Date LMSW license issued
mo. day yr.
Date registration ends
mo. day yr.
7. You must complete 2,000 client contact hours of post-MSW supervised experience in diagnosis, psychotherapy and assessment-based
treatment plans over a period of at least 36 months and no more than 6 years. You must be supervised by a licensed clinical social
worker, licensed psychologist or physician who meets the requirements of section 74.6 of the Commissioner’s Regulations in an
acceptable setting as defined in section 74.6.
Name of supervisor
Name of setting
Setting address
8. I declare and affirm that the statements made in the foregoing application, including accompanying statements are true, complete and
correct. I understand that any false or misleading information in, or in connection with my application may be cause for denial of licensure
and may lead to a filing of charges of professional misconduct.
Applicant's Signature Date
Licensed Clinical Social Worker Form 4B, Page 1 of 3, Revised 9/17
Section II - Supervisor's Certification of Supervised Experience
Instructions for Completing Section II: Read the attached Appendix A and complete all of Section II. Be sure to sign the affidavit 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 returned by the applicant. By completing Section II,
you are certifying that the person named in Section I will received supervision that meets the requirements as defined in Education Law and the Commissioner's
Regulations. Note: If you are a licensed colleague attesting to the supervision provided by a qualified supervisor who is not available, and the experience has
been completed, you must provide the name and qualifications of the supervisor in item 2 and complete the rest of the information in Section II.
1. Name of the applicant
(see Section I, item 3)
2. Supervisor name
I am licensed and currently registered to practice as a (check all that apply)
Licensed Clinical Social Worker
License Number
Jurisdiction
License date
mo. day yr.
Licensed Psychologist
License Number
Jurisdiction
License date
mo. day yr.
Licensed Physician
License Number
Jurisdiction
License date
mo. day yr.
Certified in psychiatry?
Yes No
If "yes", ABPN certificate number
3. Please identify the employment setting below and attach the operating certificate, NYSED waiver or certificate of incorporation that
authorizes the entity to employ LMSWs and LCSWs.
Agency/Practice Name
Type of Setting (check one)
Private practice owned by supervisor (LCSW, Licensed psychologist or psychiatrist)
Professional entity (PLLC, PLLP, P.C.) owned by supervisor (attached consent from SED)
Sole proprietorship or other entity authorized under law (attach certificate of corporation)
Program approved by the New York State Office of Mental Health (OMH), Office for People with Developmental Disabilities (OPWDD),Office of
Alcoholism & Substance Abuse Services (OASAS), Office of Children & Family Services (OCFS), Department of Corrections and Community
Supervision (DOCCS), State Office for the Aging, or local social service or mental hygiene district (attach operating certificate)
Department of Health (DOH) approved hospital or nursing home (attach copy of operating certificate)
Psychotherapy institute chartered by Board of Regents and authorized to provide psychotherapy to the public (attach copy of Regents Charter)
Elementary, middle, high school or college authorized to provide psychotherapy services to students (attach copy of authorization)
Not-for-profit or other entity authorized by waiver from the State Education Department to employ licensed professionals and provide services
(attach waiver and certificate of incorporation)
Other (describe)
4. Was the supervised experience for the above named applicant completed outside of New York State?
Yes No
If yes, the supervisor must complete and submit Form 4Q for review.
5. Have you completed and retained a record of client contact hours and supervision hours of the applicant while under your supervision?
Yes No
6. Supervision period: starting
mo. day yr.
ending
mo. day yr.
Total number of client contact hours of psychotherapy provided during the period you supervised the applicant
Total number of supervision hours you provided
Licensed Clinical Social Worker Form 4B, Page 2 of 3, Revised 9/17
Section II - Supervisor's Certification of Supervised Experience (continued)
Attestation
I hereby certify that I have read Appendix A and that I meet the requirements to supervise experience for LCSWs. I hereby declare and affirm
that I am knowledgeable about, and qualified to attest to, the applicant's work and the work experience and ability and that the work experience
described is true and accurate. I understand that any false or misleading information on this form, or related to verification of this applicant's
experience, may be cause for charges of misconduct and/or criminal prosecution.
Supervisor Signature Date
Print Name
Address
Telephone Fax
Email
Note: If supervisor was not employed by the agency, please provide a copy of the signed agreement between the employer, supervisor and
applicant indicating that third-party supervision was authorized and patients were informed as to the sharing of confidential information.
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 4B, Page 3 of 3, Revised 9/17
Reset Form
Psychotherapy Log
Use this weekly log to document the applicant's hours of practice and supervision for Licensed Clinical Social Work. All pages
of this log must be retained by the supervisor and submitted upon request of the Department. Please copy this log as needed.
Page
of
Applicant name Supervisor name
Client Contact
Hours/Week*
Applicant Initials
Supervision Type
(Individual or Group)**
Supervision
Hours/Week
Supervisor Initials
Week starting date for
psychotherapy
(mo./day/yr.)
*Client contact hour = 45 minutes of psychotherapy (shorter sessions may be combined)
Licensed Clinical Social Worker Psychotherapy Log, Revised 9/17
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Completed 3 February 2020

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