Fillable Licensed Clinical Social Worker Form 6 Plan for (New York State Education Department)

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Licensed Clinical Social Worker Form 6 Plan for (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 6
Plan for Supervised Experience
Application for Licensed Clinical Social Worker
73 $10 MI
A Licensed Master Social Worker (LMSW) must be registered to practice in New York State and may only provide clinical social work services, including
psychotherapy, under the supervision of a Licensed Clinical Social Worker (LCSW), licensed psychologist or licensed physician who is board-certified in
psychiatry in an authorized setting, as defined in Education Law and Commissioner's Regulations. The setting is responsible for employing the LMSW and the
qualified supervisor to provide clinical social work services; a LMSW cannot employ or contract with a supervisor.
Prior to starting your supervised experience, you can verify the license status of your proposed supervisor on the Office of the Professions' web site at
www.op.nysed.gov/opsearches.htm. This form must be submitted prior to being employed or supervised by your proposed supervisor. This form will not be
reviewed if submitted after the supervised experience has been completed
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. Use the
psychotherapy log to document your hours of practice and supervision.
2. Send the entire form along with a copy of Appendix A to your supervisor and ask him/her to complete Section II. Return all pages along with the $10 fee
directly to the Office of the Professions at the address at the end of the form.
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 Name
Last
First
Middle
Licensee business address, phone and email address are public information. Failure to
indicate business or home on this form for each item will deem it public information.
4. Mailing Address Home or Business
(You must notify the Department within 30 days of any address or name changes)
Line 1
Line 2
Line 3
City
State ZIP Code
Country/
Province
5. Telephone/Email Address
Daytime Phone
Home or Business
Area Code Phone
Email Address (please print clearly)
Home or Business
6. New York State DMV ID Number
(Driver or Non-Driver ID)
(Leave this blank if you do not have a
New York State DMV ID Number)
7.
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.
8.
You must complete 2000 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 have been 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 clinical supervisor
Name of setting
Setting address
9. 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.
Signature Date
Licensed Clinical Social Worker Form 6, Page 1 of 2, Rev. 10/20
Section II: Supervisor's Verification of Plan for Experience
Instructions to the Supervisor: 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 Applicant. By completing Section II, you are certifying that the person named in Section I will receive supervision that
meets the requirements as defined in Education Law and the Commissioner's Regulations.
1.
Name of the applicant
(see Section I, item 3)
2. Supervisor Name
I am licensed and currently registered to practice in New York State as a (check all that apply)
Licensed Clinical Social Worker
License number
License date
mo. day yr.
Licensed Psychologist
License number
License date
mo. day yr.
Licensed Physician
License number
License date
mo. day yr.
Are you ABPN 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
Addiction Services and Supports (OASAS), Office of Children & Family Services (OCFS), Department of Corrections and Community Supervision
(DOCCS), State Office for the Aging, Department of Health or local social service or mental hygiene district (attach operating certificate)
Elementary, middle, high school or college authorized to provide psychotherapy services to students (attach copy of authorization)
Psychotherapy institute chartered by Board of Regents and authorized to provide psychotherapy to the public (attach copy of Regents Charter)
Not-for-profit or other entity authorized by waiver from the State Education Department to employ licensed professionals and provide services (attach
6503-a or 6503-b waiver and certificate of incorporation)
Other (describe)
Agency/Practice address
Agency/Practice Phone
Fax
Email
Agency/Practice web site
The supervisor must be employed by the same agency as the LMSW and have access to all patient files and records; have responsibility
for the assessment, evaluation and treatment of each patient diagnosed and treated by the LMSW practicing under his/her supervision;
and each patient must consent to treatment by the supervised LMSW.
Attestation
I hereby certify that I have read Appendix A and that I meet the requirements to supervise a LMSW. I understand that the information above
will be used to review the applicant's experience, all answers given are truthful and accurate to the best of my ability.
Supervisor Signature Date
Print Name
Address
Telephone Fax
Email
If you are submitting an initial Form 6, mail this form and appropriate fee to: New York State Education Department, Office of the
Professions, PO Box 22063, Albany, NY 12201, U.S.A.. DO NOT SEND CASH. Make check or money order payable to the New York State
Education Department.
Licensed Clinical Social Worker Form 6, Page 2 of 2, Rev. 10/20
Licensed Clinical Social Worker, Appendix A, Requirements for Supervised Experience LMSW
You must document the completion of three years of post-graduate full-time supervised clinical social work experience in diagnosis,
psychotherapy, and assessment-based treatment plans, or the part-time equivalent, or combination of full-time and part-time supervised
clinical social work in no more than six consecutive years.
Experience shall consist of not less than 2,000 client contact hours over the course of three years but not to exceed six calendar years. All
experience must be obtained in a setting acceptable to the Department after completion of the professional education required for licensure.
Qualified Supervisor
The experience must be supervised by an individual who is licensed and registered to practice as a(n):
●
Psychologist who, at the time of supervision of the applicant, was licensed as a psychologist in the state where supervision occurred, was
qualified in psychotherapy as determined by the Department based upon the Department's review of the psychologist's education and
training, including but not limited to education and training in psychotherapy obtained through completion of a program in psychotherapy
registered pursuant to Part 52 of the Regulations of the Commissioner of Education or a program in psychology accredited by the
American Psychological Association; or
●
Physician who, at the time of supervision of the applicant, was a diplomate in psychiatry of the American Board of Psychiatry and
Neurology, Inc. or had the equivalent training and experience as determined by the Department.
●
LCSW in New York State or the equivalent as determined by the Department; or
A supervisor who is not licensed in New York State must submit an Approval of Qualifications to Supervise Psychotherapy (Form 4Q) to allow
the Department to determine whether the supervisor is qualified in diagnosis, psychotherapy and assessment-based treatment planning.
A supervisor may not have a familial relationship with the applicant, as such dual relationships may constitute a charge of unprofessional
conduct under the Education Law and Regents Rules.
Supervision Sessions
The supervision must consist of at least 100 hours of in-person individual or group clinical supervision distributed over the period of the
supervised experience. During each supervision session:
●
your supervisor must provide the diagnosis and appropriate treatment for each client;
●
your cases must be discussed with your supervisor; and
●
your supervisor must provide you with oversight and guidance in diagnosis and treating clients.
The supervisor is legally and professionally responsible for the diagnosis and treatment of each client and must have access to all relevant
information. It is the responsibility of your employer to provide appropriate supervision as an LMSW may only practice clinical social work
under supervision. Any arrangements for third-party supervision must include a written agreement between the employer, third-party
supervisor and the LMSW to specify the supervisor's access to clients and client records to ensure appropriate supervision of the LMSW. The
client must be informed of how confidential information is handled in the case of third-party supervision and how to raise questions with the
employer and/or third-party supervisor.
Setting for the Experience
All experience that is completed in New York State must be in a setting that is legally authorized to provide psychotherapy and clinical social
work services. An acceptable setting is:
●
A professional corporation, professional limited liability partnership or professional limited liability corporation that is authorized to provide
services that include psychotherapy;
●
A professional service corporation, registered limited liability partnership, or professional service limited liability company authorized to
provide services that are within the scope of practice of licensed clinical social work;
●
A sole proprietorship owned by a licensee who provides services that are within the scope of his or her profession and services that are
within the scope of licensed clinical social work;
●
A program or service approved by the New York State Office of Mental Health (OMH), Office for People with Developmental Disabilities (OPWDD),Office
Addiction Services and Supports (OASAS), Office of Children & Family Services (OCFS), Department of Corrections and Community Supervision
(DOCCS), Department of Health (DOH), State Office for the Aging, or local social service or mental hygiene district (attach operating certificate);
●
A program or facility authorized under federal law, such as the Veterans’ Administration, to provide health services including
psychotherapy;
●
A public elementary, middle or high school authorized by the Education Department to provide school social work services as defined in
Part 80-2.3 of the Commissioner’s Regulations, including clinical social work;
●
An entity defined as exempt from the licensing requirements under New York Law or otherwise authorized under New York Law of the
laws of the jurisdiction in which the entity is located to provide services, including psychotherapy.
In New York State, a general business corporation or not-for-profit corporation may not provide professional services or employ licensed
professionals unless authorized under law. The certificate of incorporation should clarify the purpose of the entity and whether licensed
professionals may be employed to provide services that are restricted under Title VIII of the Education Law.
It is your responsibility to practice only under a qualified supervisor and in an authorized setting. You should review the supervisor
qualifications and acceptable experience with an employer before you accept a position practicing clinical social work.
Licensed Clinical Social Worker, Appendix A, Rev. 10/20
Psychotherapy Log
Use this weekly log to document the applicant's hours of practice and supervision for Licensed Clinical Social Worker. 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**
Supervisor Initials
Week starting date for
psychotherapy
(mo./day/yr.)
*Client contact hour = 45 minutes of psychotherapy (shorter sessions may be combined)
**Supervision = at least 100 hours of in person supervision given by the attesting supervisor
Licensed Clinical Social Worker Psychotherapy Log, Rev. 10/20
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Completed 28 October 2021

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