Fill - Free fillable Licensure Process for LMSW/LBSW Mail completed Application for (Missouri) PDF form

Licensure Process for LMSW/LBSW

• Mail completed Application for Licensure form with the appropriate fee

• Fingerprint results (instructions included with application)

• Have your college/university mail an official transcript directly to our office. If you are requesting to

sit for the examination prior to graduation, have your school send a letter stating you’re on track to graduate.

You are responsible for ensuring your school sends a final transcript upon graduation, a license WILL NOT

be issued without one.

• The Committee will notify the applicant via email to contact ASWB and schedule the exam once the

application has been reviewed and approved. Upon passing the exam, the ASWB will send our office your

official score report and the license will be issued.

Licensure Process for LCSW/LAMSW (must hold a current license as a LMSW in MO)

• Register supervision by submitting the following for approval:

◊ Registration of Supervision form and required fee

◊ Employment Verification Letter

• Upon approval, complete a minimum of 3,000 hours of supervised experience within 24-48 months.

• The supervision and the ability to practice clinically will cease at the end of the 48 month period. If one

has not passed the clinical exam in that time period they may still be approved to take the exam,

providing the supervision still qualifies as per 20 CSR 2263-2.032(10).

• After obtaining the required supervision, complete and submit the following:

◊ Application for Licensure form and fee

◊ Fingerprint results (instructions included with application)

◊ Attestation form (must come directly from supervisor)

• The Committee will notify the applicant via email to contact ASWB and schedule the exam once

the application has been reviewed and approved. Upon passing the exam, the ASWB will send our

office your official score report and the license will be issued. You must remain under

supervision until the exam is passed and the license is issued and received in order to

provide clinical services.

Should you …

• Should you choose, upon completion of 75% (18 months and 2,250 hours) of the supervision you may

sit early for the exam. This is done by submission of application, fingerprints and email from

supervisor that the applicant is on track to complete the required supervision

• Should you change supervisor AND/OR setting during the licensure process, the Registration of

Supervision/Change of Status form along with a $25 fee must be submitted before beginning the

supervision. The $25 fee is submitted for each Registration of Supervision/Change of Status form

submitted.

Please review the rules and statutes for all licensure and supervision requirements. You can find

those, as well as all the forms needed, online at

www.pr.mo.gov/socialworkers

STATE COMMITTEE FOR SOCIAL WORKERS

3605 Missouri Boulevard

P.O. Box 1335

Jefferson City, MO 65102-1335

Telephone: (573) 751-0885

Fax: (573) 526-4220

800-735-2966 TTY Relay Missouri

800-735-2466 Voice Relay Missouri

lcsw@pr.mo.gov

http://www.pr.mo.gov

Application for Licensure – LCSW/LAMSW

**Effective April 30, 2010**

Dear Sir/Madam,

Thank you for your interest in obtaining the materials to apply for a licensed clinical or advanced macro social

worker in Missouri. Attached you will find the following information:

1. Application for Licensure Form (Original signature required)

2. Instructions for completing the required fingerprinting/background check

3. Attestation of Supervised Social Work Experience form(s) (Directly from the supervisor only /

original signature)

Application for Licensure files are not considered complete until ALL the following information has been

received in the committee office:

1. Completed Application for Licensure form (Original signature required)

2. Fingerprinting/Background check results (valid for one (1) year)

3. Application for Licensure fee

4. Completed Attestation of Supervised Social Work Experience form(s) (Directly from the supervisor

only / original signature)

5. Evidence of completion of two (2) hours of suicide prevention training

6. Passing exam score from the ASWB

You will be notified by the committee office in writing after items 1-5 (above) have been received with

instructions on contacting the ASWB to schedule for the appropriate examination.

An applicant for licensure who answers “yes” to any question in the application which relates to possible grounds

for denial of licensure under section 337.630, RSMo, shall submit a sworn affidavit setting forth in detail the facts

that explain the answer and shall submit copies of appropriate documents related to that answer, if requested by

the committee.

The committee reminds you to read the rules & statutes regarding licensure. Should you have any questions,

please contact the committee office at 573.751.0885 or lcsw@pr.mo.gov

Revised 7/10/2019

MO 375-0902 (3-2021)

NAME (FIRST, MIDDLE, LAST, SUFFIX, FORMER/MAIDEN)

RESIDENCE STREET ADDRESS (IF PO, PLEASE PROVIDE A STREET ADDRESS ALSO) CITY STATE ZIP CODE

SOCIAL SECURITY NUMBER DATE OF BIRTH RESIDENCE TELEPHONE NUMBER

CURRENT PLACE OF EMPLOYMENT EMPLOYMENT TELEPHONE NUMBER

EMPLOYMENT ADDRESS CITY STATE ZIP CODE

E-MAIL U.S. CITIZEN?

YES NO (IF NO, ATTACH COPY OF EVIDENCE OF LEGAL RESIDENT ALIEN STATUS)

SOCIAL WORK DEGREES:

SCHOOL NAME LOCATION DATE CONFERRED

DOCTORATE

SCHOOL NAME LOCATION DATE CONFERRED

MASTER

SCHOOL NAME LOCATION DATE CONFERRED

BACCALAUREATE

LIST ALL OF THE STATES IN WHICH YOU NOW HOLD OR HAVE EVER HELD A LICENSE/CERTIFICATE TO PRACTICE SOCIAL WORK IN ORDER

OF ATTAINMENT. IF CURRENT STATUS IS “OTHER”, PLEASE EXPLAIN ON SEPARATE SHEET.

LICENSE/CERTIFICATE NUMBER AND

STATE ISSUE DATE CURRENT STATUS

TITLE CONFERRED BY LICENSE OR CERTIFICATE

ACTIVE INACTIVE OTHER

ANSWER THE FOLLOWING QUESTIONS (Yes answers must be explained in sworn affidavit and accompanied by

YES NO

documents as required in the rules.)

a) Have you ever applied for a license as a social worker and been denied?

b) Has your license or social work privileges ever been revoked, restricted, or have you ever been the subject

of disciplinary action by any licensing agency, institution or any other entity?

c) Have you ever entered a plea of guilty or nolo contendere or been convicted of a felony, misdemeanor or

received a suspended imposition of sentence?

d) Are you presently being investigated or is there any disciplinary action pending against you?

e) Are you now or ever have been addicted to or used in excess, any drug or chemical substance including

alcohol?

f) Are you now being treated or have you ever been treated through a drug or alcohol rehabilitation program?

g) Have you ever been named as a party in a civil suit?

h) Have you ever been disciplined for unethical behavior or unprofessional conduct?

i) Have you ever voluntarily surrendered a professional license?

MO 375-0902 (3-2021)

INSTRUCTIONS

APPLICANT DATA

FEES

Attach application fee. $70

1. Applicant must complete all sections, including reference page.

2. If additional information is needed for any questions, please attach a separate sheet.

3. Complete applications should be mailed to the following central office address:

DIVISION OF PROFESSIONAL REGISTRATION/

STATE COMMITTEE FOR SOCIAL WORKERS

P.O. BOX 1335

JEFFERSON CITY, MISSOURI 65102-1335

TELEPHONE: (573) 751-0885 TDD 800-735-2966

http://www.pr.mo.gov E-mail: lcsw@pr.mo.gov

PLEASE CHECK ONE OF THE FOLLOWING

CLINICAL SOCIAL WORKER ADVANCED MACRO SOCIAL WORKER

MISSOURI DIVISION OF PROFESSIONAL REGISTRATION

STATE COMMITTEE FOR SOCIAL WORKERS

STATE OF MISSOURI

DIVISION OF PROFESSIONAL REGISTRATION

APPLICATION FOR LICENSURE - LCSW/LAMSW

MO 375-0902 (3-2021)

VI. AFFIDAVIT

I, the below named applicant, being duly sworn, hereby affirm under penalties of perjury that I am the applicant referred to

in the preceding application for a license to practice as a clinical or advanced macro social worker in the State of Missouri,

and that all statements and enclosures are true and accurate to the best of my knowledge, information and belief.

I submit for consideration the above proofs as required by the Missouri law governing the practice of clinical or advanced

macro social work and subject to the rules and regulations of the Division of Professional Registration/State Committee for

Social Workers. The Division may require further evidence that it deems reasonable and proper from the sources above.

Enclosed is the application fee made payable to the Division of Professional Registration, which is not refundable, in the

form of a money order, personal check, cashier’s check or bank draft.

MUST BE SIGNED

APPLICANT SIGNATURE

IN PRESENCE OF

NOTARY PUBLIC

NOTARY PUBLIC EMBOSSER OR STATE OF COUNTY (OR CITY OF ST. LOUIS)

BLACK INK RUBBER STAMP SEAL

SUBSCRIBED AND SWORN BEFORE ME, THIS

DAY OF 19

USE RUBBER STAMP IN CLEAR AREA BELOW.

NOTARY PUBLIC SIGNATURE MY COMMISSION

EXPIRES

NOTARY PUBLIC NAME (TYPED OR PRINTED)

EXAMINATION REQUESTED

CLINICAL ADVANCED GENERALIST

EXAM RESULTS: Applicant is responsible for having the Association of Social Work Boards submit verification of a passing score as

determined by the Committee.

STATE OF MISSOURI

DIVISION OF PROFESSIONAL REGISTRATION

SUICIDE ASSESSMENT, TREATMENT, REFERRAL

AND MANAGEMENT

MISSOURI DIVISION OF PROFESSIONAL REGISTRATION

STATE COMMITTEE FOR SOCIAL WORKERS

I hereby attest that on ______________________________________ Icompleted a minimum of 2 hours of training the areas of suicide,

(DATE)

assessment, treatment, referrals and management.

SIGNATURE DATE

MO 375-1037 (9-18)

OURI DIVISION OF PROFESSIONAL REGISTRATION

E COMMITTEE FOR SOCIAL WORKERS

STATE OF MISSOURI

MISS

DIVISION OF PROFESSIONAL REGISTRATION

STAT

ATTESTATION OF SUPERVISED SOCIAL WORK EXPERIENCE

SUPERVISION TERMINATION -

SUPERVISEE PLEASE CHECK ONE OF THE FOLLOWING

Clinical Supervision Advanced Macro Supervision

SUPERVISOR EMAIL ADDRESS

SUPERVISION SETTING BEGIN DATE (MONTH/DAY/YEAR) END DATE (MONTH/DAY/YEAR) # MONTHS

ADDITIONAL SETTINGS BEGIN DATE END DATE # MONTHS

AVERAGE HOURS SPENT IN WEEKLY SUPERVISION AVERAGE NUMBER OF HOURS WORKED WEEKLY IN A SOCIAL WORK POSITION DURING THIS TIME PERIOD

Individual: Group:

Social Work Practice

1. Human and personality development

2. Psycho and group dynamics

3. Family dynamics

4. Psychopathology

5. Crisis intervention

6. Human relations

7. Interactive effect of biological functioning on the client system

8. Interactive effect of psychosocial functioning on the client system

Social Work Practice

1. Assessing personality functioning/dysfunction

2. Assessing client system functioning/dysfunction

3. Evaluation of clientele and agency program policies and practices

4. Appropriate selection of intervention, including crisis, strategies and

techniques in decision making

5. Appropriate timing and handling of termination process

6. Integration of theory and practice skill

7. Seeking and using appropriate consultation with other disciplinary

sources

8. Ability to use supervision to enhance professional growth

9. Willingness to conduct periodic critical review of work & performance

10. Self-awareness & disciplined use of self in professional

relationships

Not

Above

Evaluate the applicant/supervisee on the following:

Poor Average

Superior

Observed

Average

RECOMMENDATION FOR LICENSURE SUBMITTING THE FORM AS:

Without Reservation With Reservation Do Not Recommend Attestation Supervision Termination

PLEASE PROVIDE AN EXPLANATION AS TO WHY SUPERVISION IS BEING TERMINATED AND ANY ADDITIONAL INFORMATION REGARDING THE EVALUATION ABOVE THAT YOU CONSIDER RELEVANT.

I certify that the information above is true and correct to the best of my knowledge. I fully understand that all statements made on this form are subject to

verification and that any false and misleading answer may be grounds for refusal or subsequent revocation or suspension of my license.

SIGNATURE OF SUPERVISOR DATE

The supervisor must mail the original of this form to the State Committee for Social Workers, P.O. Box 1335, Jefferson City, MO 65102-1335 within 14 days

from the termination of supervision. Fax or email will not be accepted.

MO 375-0250 (1-2021)

Save

Reset

IMPORTANT NOTICE

TO:

FROM:

RE:

DATE:

Applicants

anessa Beauchamp, Executive Director

Criminal Background Checks – Fingerprinting Requirements

February 24, 2021

The State Committee for Social Worker uses IdentoGo to fingerprint applicants

for licensure/

registration.

The 4 digit code is 5416 (for ALL applicants within or outside Missouri).

 Individuals needing to be fingerprinted WITHIN the State of Missouri.

 Applicants will need to register with the Missouri Automated Criminal History Site

(MACHS) at www.machs.mo.gov OR telephone 1-844-543-9712 (IDEMIA).

 Upon completing the registration you will be routed to the IdentoGo website for

selection of fingerprint card processing.

 Upon completing the registration you will receive an 8 digit Transaction Control

Number (TCN). This number will be used to track your fingerprints through the

background check process.

 An email notification will be sent once registration has been complete with a link to a

Printable Service Summary and basic instructions

 Individuals needing to be fingerprinted OUTSIDE of the State of Missouri.

 Applicants will need to contact the office via email lcsw@pr.mo.gov to request a

fingerprint card (FD-258) to be mailed directly to them via postal service.

 Out–of-state applicants will take their fingerprint cards to their local Highway Patrol

office for fingerprinting. The fingerprints may be traditional ink rolled or LiveScan.

 Upon completing the card requirements, applicants will need to register with the

Missouri Automated Criminal History Site (MACHS) at www.machs.mshp.dps.mo.gov

OR telephone 1-844-543-9712 (IDEMIA).

 Upon completing the registration you will be routed to the IdentoGo website for

selection of fingerprint card processing.

 Mail the signed pre-enrollment confirmation page and the completed fingerprint card

to the below address:

IdentoGO

Cardscan Department – Missouri Program

340 Seven Springs Way, Suite 250

Brentwood, TN 37027

NOTE:

DO NOT submit fingerprints or fingerprint fees to the office.

Section One: Agency Information

AGENCY 4-DIGIT MACHS REGISTRATION NUMBER: ______________

Agency Name: ________________________________________________________________________________

Agency ORI: __________________________________________ Agency OCA: ___________________________

Section Two: The Missouri Automated Criminal History Site (MACHS)

For fingerprinting services through the state electronic fingerprint vendor, you must first register with the Missouri

Automated Criminal History Site (MACHS). If you do not have internet access, you may contact the vendor

(IDEMIA) at 844-543-9712 for assistance with registration.

MACHS Registration Instructions:

1. Log-on to www.machs.mo.gov

2. Click on the "blue box" Click here to register with the fingerprint portal

3. Click on the "blue box" Click here to register with MACHS

4. Enter the 4-digit registration number provided by your agency. Click "enter"

5. Enter your personal information in the appropriate fields and proceed through the registration process.

6. Near the end of registration, you will be asked to verify all personal data and agency information before

proceeding. If all information entered is accurate and complete, click “complete registration.” This will redirect

you to IDEMIA’s website for further instruction.

7. Please note your Transaction Control Number (TCN) for future reference.

8. Email and/or phone number, and Date of Birth will be required at the fingerprint vendor location to search for

your registration transaction.

The processing fee is automatically calculated based on the 4-digit registration number that was entered at the

beginning of registration. All fees are payable to IDEMIA at the time of fingerprinting unless a billing account has

been established by your agency.

Once fingerprinting is completed, IDEMIA will transmit your photo, personal data, and fingerprint images to the

Missouri State Highway Patrol (MSHP) for processing. The results of the search will be provided to the authorized

agency within approximately 1-5 business days. NOTE: IDEMIA does not have access to criminal history. For

questions about your results, contact the requesting agency or MSHP. Please reference your TCN.

Missouri State Highway Patrol

Applicant Fingerprint Services of Missouri

Applicant Fingerprint Form for State and FBI Criminal History Background Checks

SHP-984D 08/18

Reset Form

Print Form

5416

State Committee for Social Workers

MO920681Z

Last updated: July 2018 https://www.identogo.com/locations/missouri

Missouri Non-Resident Cardscan

Universal Enrollment Platform Processing Overview

Cardscan processing is available for those applicants residing outside of Missouri or physically unable to

visit an IdentoGo location. In order to complete the process, applicants must complete the following

steps.

1. An Applicant should obtain a set of fingerprints from a local law enforcement agency or other

entity that provides fingerprinting services. These fingerprints may be either traditional ink

rolled fingerprints on a FBI (FD-258) fingerprint card or LiveScan fingerprints printed to a FBI (FD-

258) fingerprint card.

*Please provide the following information to the technician capturing the fingerprints*

 Capturing Four-Finger Slaps:

o Fingers must be placed vertically, straight up-and-down, when

capturing the four-finger slaps as depicted to the right:

o Missouri State Highway Patrol will reject or refuse to process any

fingerprint cards that have the four finger slap prints at an angle.

 Capturing Individual Fingers:

o Each finger and thumb will need to be rolled completely from one side of the

fingernail to the other side of the fingernail.

o Missouri State Highway Patrol will reject and refuse to process any fingerprint card

that contains non-rolled fingerprints.

 Submitting Fingerprint Cards:

o Fingerprints may be submitted on standard FD-258 FBI applicant cards

o The fingerprint card must be completely filled-out in legible print. The following

information must be included or the Fingerprint Card will not be processed:

 Full name

 Date of birth

 Social Security Number

 Home address

 Sex

 Height

 Weight

 Hair color

 Eye color

 Place of birth (state or country only)

 Citizenship

Last updated: July 2018 https://www.identogo.com/locations/missouri

2. Once fingerprints are captured on a fingerprint card and the individuals demographic data is

completely filled-out on the fingerprint card, please follow the steps listed below:

 Pre-enroll on the MACHS system at www.machs.mshp.dps.mo.gov/.

 After registering, the applicant will be routed to the IdentoGO website for selection of

Fingerprint Card Processing.

i. All processing fees will be collected during the pre-enrollment process.

ii. A pre-enrollment confirmation page will be provided once registration is

complete.

 Print and sign the completed pre-enrollment confirmation page, which includes the barcode

printed on the top right of the page.

 Mail the signed pre-enrollment confirmation page and the completed fingerprint card to:

IdentoGO

Cardscan Department – Missouri Program

340 Seven Springs Way, Suite 250

Brentwood, TN 37027

 For further instructions, each applicant should contact their employer or agency contacts for

those details.

Please review the following pages for more detailed instructions regarding the Universal Enrollment

Platform Pre-Enrollment process. More information can be found on the IdentoGo Missouri website,

found at https://www.identogo.com/locations/missouri.

Last updated: July 2018 https://www.identogo.com/locations/missouri

Directions for Pre-enrollment and Payment – Required for ALL Fingerprint Cards

1. Complete registration on the MACHS page (www.machs.mshp.dps.mo.gov/) using the 4-digit

registration code provided by the requesting agency.

2. After entering their demographic information is complete, applicant will be routed to the

IdentoGO page for completion.

3. Confirm information displayed is correct.

4. Select “Register for Fingerprint Card Processing Service”.

5. Confirm you would like to submit Fingerprint Cards by clicking “yes”.

6. Confirm Date of Birth by re-entering applicant Date of Birth, then click “Next”.

Last updated: July 2018 https://www.identogo.com/locations/missouri

7. Pay using an authorization code provided by agency or employer, or pay with credit card. Once

payment information has been entered, click “Submit”.

8. Once you have submitted your payment, you will be directed to the final registration page. You

will need to complete sections 2 and 3 after printing. Submit this page along with your

fingerprint card for processing to the address listed in Section 4. An example of the final screen

is shown below.

Last updated: July 2018 https://www.identogo.com/locations/missouri

9. An e-mail notification will be sent once registration has been complete with a link to a Printable

Service Summary and basic instructions.

AGENCY PRIVACY REQUIREMENTS FOR NONCRIMINAL JUSTICE APPLICANTS

Authorized governmental and non-gove

rnmental agencies/officials that conduct a national

fingerprint-based criminal history record check on an applicant for a noncriminal justice purpose

(such as employment or a license, immigration or naturalization matter, security clearance, or

adoption) are obligated to ensure the applicant is provided certain notice and other information

and that the results of the check are handled in a manner that protects the applicant’s privacy.

These obligations are pursuant to the Privacy Act of 1974, Title 5, United States Code (U.S.C.)

Section 552a, and Title 28, Code of Federal Regulations (CFR), Section 50.12, among other

authorities.

• Officials must provide to the applicant written notifi

cation

that his/her fingerprints will be

used to check the criminal history records of the FBI.

• Officials must ensure that an applicant receives, a

nd acknowledges receipt of, an adequate

Privacy Act Statement when the applicant submits his/her fingerprints and associated

personal information.

• Officials using the FBI criminal history record (if one exists) to make a determination of the

applicant’s suitability for the employment, license, or other benefit must provide the

applicant the opportunity to complete or challenge the accuracy of the information in the

record.

• Officials must advise the applicant that procedures for obtaining a change, correction, or

upda

te of an FBI criminal history record are set forth at 28 CFR 16.34.

• Officials should not deny the em

ployment, license, or other benefit based on information in

the criminal history record until the applicant has been afforded a reasonable time to

correct or complete the record or has declined to do so.

• Officials must use the criminal history record solely for the purpose requested and canno

disseminate the record outside the receiving department, related agency, or other

authorized entity.

The FBI has no objection to officials providing a copy of the applicant’s FBI criminal history

record to the applicant for review and possible challenge when the record was obtained based on

positive fingerprint identification. If agency policy permits, this courtesy will save the applicant the

time and additional FBI fee to obtain his/her record directly from the FBI by following the

procedures found at 28 CFR 16.30 through 16.34. It will also allow the officials to make a more

timely determination of the applicant’s suitability.

Each agency should establish and document the process/procedures it utilizes for how/when it gives

e applicant notice, what constitutes “a reasonable time” for the applicant to correct or complete

the record, and any applicant appeal process that is afforded the applicant. Such documentation

will assist State and/or FBI auditors during periodic compliance reviews on use of criminal history

records for noncriminal justice purposes.

Written notification includes electronic notification, but excludes oral notification.

See https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement

See 5 U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616), Article IV(c);

28 CFR 20.21(c), 20.33(d), 50.12(b) and 906.2(d).

Updated 05/10/2017

Non-substantive updates incorporated in January 2018

Privacy Act Statement

This privacy act statement is located on the back of the FD-258 fingerprint card.

Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and

associated information is generally authorized under 28 U.S.C. 534. Depending on the

nature of your application, supplemental authorities include Federal statutes, State

statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal

regulations. Providing your fingerprints and associated information is voluntary;

however, failure to do so may affect completion or approval of your application.

Principal Purpose: Certain determinations, such as employment, licensing, and security

clearances, may be predicated on fingerprint-based background checks. Your

fingerprints and associated information/biometrics may be provided to the employing,

investigating, or otherwise responsible agency, and/or the FBI for the purpose of

comparing your fingerprints to other fingerprints in the FBI’s Next Generation

Identification (NGI) system or its successor systems (including civil, criminal, and latent

fingerprint repositories) or other available records of the employing, investigating, or

otherwise responsible agency. The FBI may retain your fingerprints and associated

information/biometrics in NGI after the completion of this application and, while

retained, your fingerprints may continue to be compared against other fingerprints

submitted to or retained by NGI.

Routine Uses: During the processing of this application and for as long thereafter as your

fingerprints and associated information/biometrics are retained in NGI, your information

may be disclosed pursuant to your consent, and may be disclosed without your consent as

permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be

published at any time in the Federal Register, including the Routine Uses for the NGI

system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to,

disclosures to: employing, governmental or authorized non-governmental agencies

responsible for employment, contracting, licensing, security clearances, and other

suitability determinations; local, state, tribal, or federal law enforcement agencies;

criminal justice agencies;

and agencies responsible for national security or public safety.

As of 03/30/2018

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