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 4F
Certification of Licensed Experience
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 7.
2. Send the entire form along to your colleague to complete Section II. The colleague must return both pages of the form directly to the
Office of the Professions at the address at the end of the form. This form will not be accepted if returned by the applicant.
Applicant Instructions
Assigned Number (from Form 4E):
This form is for applicants seeking licensure in New York State by endorsement of a license to practice clinical social work issued in
another jurisdiction. You must have at least 10 years of licensed experience in clinical social work, in the 15 year period prior to
applying for licensure in New York State
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 at time of employment (if different than above)
6. Name of colleague Assigned number from Form 4E
I practiced licensed clinical social worker as defined below:
“The practice of clinical social work encompasses the scope of practice of licensed master social work and, in addition, includes the
diagnosis of mental, emotional, behavioral, addictive and developmental disorders and disabilities and of the psychosocial aspects of
illness, injury, disability and impairment undertaken within a psychosocial framework; administration and interpretation of tests and
measures of psychosocial functioning; development and implementation of appropriate assessment-based treatment plans; and the
provision of crisis oriented psychotherapy and brief, short-term and long-term psychotherapy and psychotherapeutic treatment of
individuals, couples, families and groups, habilitation, psychoanalysis and behavior therapy; all undertaken for the purpose of preventing,
assessing, treating, ameliorating and resolving psychosocial dysfunction with the goal of maintaining and enhancing the mental,
emotional, behavioral, and social functioning and well-being of individuals, couples, families, small groups, organizations, communities
and society.”
Jurisdiction where I practice licensed clinical social work
Date of Licensure
mo. day yr.
License number
7. I request and give my permission to the individual 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. I also declare and affirm that the statements made in this application,
including accompanying documents, 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 or loss of licensure and may result in criminal prosecution.
Applicant's Signature Date
Licensed Clinical Social Worker Form 4F, Page 1 of 2, Revised 8/17
