Fillable Licensed Clinical Social Worker Form 4Q Approval of (New York State Education Department)

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Licensed Clinical Social Worker Form 4Q Approval of (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 4Q
Approval of Qualifications to Supervise Psychotherapy
Applicant Instructions
Complete Section I and send the entire form along with a copy of Appendix A directly to the supervisor (LCSW, psychiatrist or psychologist)
who supervised your work experience. Ask the supervisor to complete Section II and send 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. This form may be
submitted prior to the experience to confirm the eligibility of the supervisor.
Section I - Applicant Information
1. Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
2. New York State Licensed Master Social Worker License Number
3. Print Your Name Exactly As It Appears On Your Application for Licensure (Form 1)
Last
First
Middle
4. Name of Supervisor your are sending this form to
Section II - To be completed by the Supervisor
Note: Do not complete this form if you were licensed in New York State as a licensed clinical social worker, psychologist, or
physician during the time you supervised the applicant.
Instructions to Supervisor: Complete this section and return all pages of this form to the Office of the Professions at the address at the end
of the form.
1. Supervisor
Supervisor name
I am a (check all that apply)
Check type of degree
Ph.D./DSW Ed.D. Psy.D. M.S.W. M.D.
Title of Degree
Date of receipt of degree
mo. day yr.
Name of institution where you received this degree
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.
Licensed Clinical Social Worker Form 4Q, Page 1 of 3, Revised 8/17
Section II - To be completed by the Supervisor (continued)
2. Additional Qualifying Criteria (Complete all that apply for your profession)
Licensed Psychologist
a. ABPP Diplomate in
Clinical Counseling School
Year received
b. Doctorate in clinical or counseling or school psychology? Yes No
If "yes," was it from a program which was New York State registered or APA approved? Yes No
c. Did you complete a formal internship which included psychotherapy training? Yes No
If "yes," name of program
Date completed
yr.daymo.
Was the internship accredited by the APA at the time?
Yes No
d. If your doctorate was in a field other than clinical or counseling or school psychology, did you take formal
respecialization program in clinical or counseling or school psychology?
Yes No
If "yes," name of program
Date completed
mo. day yr.
Physicians
Are you ABPN certified in psychiatry?
Yes No
If "yes," ABPN Certificate Number
LCSW
A qualified supervisor must have at least three years of full-time, post-MSW supervised experience in diagnosis and psychotherapy,
prior to supervising the applicant.
Please note that other direct practice with clients does not qualify under New York State Law. In order to determine if you are qualified to
supervise, we must have the following information to evaluate your post-degree supervised experience in diagnosis and psychotherapy.
Weekly Client
Contact Hours
Hours of Individual
Supervision/Month
Hours of Group
Supervision/Month
Supervisor Name
Supervisor License Number
and Jurisdiction
Dates of Post-MSW
Experience
All Supervisors
Have you completed a prescribed postgraduate program in psychotherapy in an institute chartered by the
New York State Board of Regents or one in another jurisdiction?
Yes No
If "yes," name of institute
Date completed
mo. day yr.
Attach a copy of license and Curriculum Vitae.
Licensed Clinical Social Worker Form 4Q, Page 2 of 3, Revised 8/17
Section II - To be Completed by the Supervisor (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.
Signature Date
Print Name
Address
Telephone Fax
Email
If the supervisor is not an employee of the same agency as the applicant, please provide information about the applicant's employer:
Name of Agency/Employer
Address
Telephone Fax
Email
(where supervised experience took place)
The patient was notified that the agency authorized a third-party supervisor with access to the patient's records.
Signature Date
Name of Agency Representative
Print Name
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 4Q, Page 3 of 3, Revised 8/17
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Licensed Clinical Social Worker Form 4Q Approval of (New York State Education Department)

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Completed 4 February 2022

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