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STATE OF ARIZONA BOARD OF BEHAVIORAL HEALTH EXAMINERS

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STATE OF ARIZONA
BOARD OF BEHAVIORAL HEALTH EXAMINERS
1740 WEST ADAMS STREET, SUITE 3600
PHOENIX, AZ 85007
PHONE: 602.542.1882 FAX: 602.364.0890
Board Website: www.azbbhe.us
Email Address: information@azbbhe.us
DOUGLAS A. DUCEY TOBI ZAVALA
Governor Executive Director
APPLICATION FEE WAIVER
Effective August 3, 2018, A.R.S. § 32-3272(E) grants the Board the authority to waive the application fee for an
applicant for independent level licensure if the applicant has paid the fee to renew or apply for an associate level
license within the previous 90 days.
To determine if you are eligible for the fee waiver, please complete the
following:
Do you currently have an active Arizona Licensed Master Social Worker (LMSW) license? ☐ YES ☐ NO*
1. LMSW license expiration date:
2. Date of LMSW renewal application and fee submission:
3. Submission date of Licensed Clinical Social Worker (LCSW) application:
If the date in (2.) above is within the 90 days prior to (3.) above, you qualify for the application fee waiver.
You do not need to submit the $250.00 application fee with your LCSW application**.
If the date in (2.) above is more than 90 days prior to (3.) above, you do not qualify for the application fee
waiver. Please include the $250.00 application fee with your LCSW application.
* If you do not have an active LMSW license issued by the state of Arizona, you do not qualify for the fee waiver.
** Staff will verify the accuracy of your dates and notify you if you are not qualified for the fee waiver.
LCSW application – 10/2021
Page 1 of 14
Name:_______________________________________________ License #:______________________
LCSW application – 10/2021
Page 2 of 14
STATE OF ARIZONA
BOARD OF BEHAVIORAL HEALTH EXAMINERS
1740 WEST ADAMS STREET, SUITE 3600
PHOENIX, AZ 85007
PHONE: 602.542.1882 FAX: 602.364.0890
Board Website: www.azbbhe.us
Email Address: information@azbbhe.us
DOUGLAS A. DUCEY TOBI ZAVALA
Governor Executive Director
APPLICATION FOR CLINICAL SOCIAL WORKER LICENSURE (LCSW)
PART
I.
PERSONAL INFORMATION
S
ALUTATION
☐ MR.
☐ MS.
☐ MRS.
☐ DR.
LEGAL NAME (FIRST NAME MI LAST NAME)
P
REVIOUS LAST NAMES
(
IF APPLICABLE
)
D
ATE OF BIRTH
(
MM
/
DD
/
YYYY
)
S
OCIAL SECURITY NUMBER
C
URRENT AZ BOARD LICENSE
(
IF APPLICABLE
)
H
OME ADDRESS
P
REFERRED PHONE
ITY
S
TATE
Z
IP CODE
A
LTERNATIVE PHONE
P
REFERRED EMAIL
(
FOR APPLICATION
/
LICENSE UPDATES
)
ALTERNATIVE EMAIL
Application updates and renewal notifications will be sent via email, so at least one email
must be provided.
EMPLOYER INFORMATION
P
RIMARY EMPLOYER NAME
C
URRENT
T
ITLE
E
MPLOYER ADDRESS
ITY
S
TATE
Z
IP CODE
E
MPLOYER PHONE
NOTE: The Board will use your home address, phone number and email for communication regarding
your application. Upon licensure, your primary employer information (above) will be visible to the
public on the Board’s license verification screen. If you do not provide employer information, your
home city, state and zip will be public information. Applicants and licensees should report name
and address changes (including employment changes) within 30 days of the change. Please list
additional employers in the employment history section of the application.
Arizona Board of Behavioral Health Examiners (“Board”) licensure application Name: ___________________________________
LCSW application – 10/2021
Page 3 of 14
PART II. UNITED STATES LEGAL PRESENCE
Arizona Revised Statutes § 41-1080 requires, in general, that a person applying for a license must
submit documentation to the licensing agency that satisfactorily demonstrates that the applicant is lawfully
present in the United States.
Section 1. Citizenship or national status declaration
☐ Yes ☐ No (if no, complete Section 2)1. Are you a citizen or national of the United States?
• If yes, attach a legible copy of your proof of citizenship document. See List A for acceptable documents.
NOTE: An Arizona issued driver’s license provides acceptable proof, as do driver’s licenses issued by
other states verifying lawful presence in the US.
• Name of document provided: _______________________________ Expiration Date: _____________
Section 2. Alien status declaration
For applicants who are NOT citizens or nationals of the United States, please indicate alien status by checking the
appropriate box below. Attach a legible copy of the front and back (if applicable) of a document that evidences
your status. See List B for acceptable documents.
• Name of document provided: _______________________________ Expiration Date: _____________
“Qual
ified Alien” Status (8 U.S.C. §§ 1621(a)(1), -1641(b) and (c))
☐ 1. An alien lawfully admitted for permanent residence under the Immigration and Nationality Act (INA).
☐ 2. An alien who is granted asylum under Section 208 of the INA.
☐ 3. A refugee admitted to the United States under Section 207 of the INA
☐ 4. An alien paroled into the United States for at least one year under Section 212(d)(5) of the INA.
☐
5. An alien whose deportation is being withheld under Section 243(h) of the INA.
☐ 6. An alien granted conditional entry under Section 203(a)(7) of the INA as in effect prior to April 1, 1980.
☐ 7. An alien who is a Cuban and Haitian entrant (as defined in section 501(e) of the Refugee Education
Assistance Act of 1980).
☐ 8. An alien who is, or whose child or child’s parent is a “battered alien” or an alien subjected to extreme
cruelty in the United States.
Nonimmigrant Status (8 U.S.C. § 1621(a)(2))
☐ 9. A nonimmigrant under the Immigration and Nationality Act [8 U.S.C. § 1101 et seq.] Nonimmigrants are
persons who have temporary status for a specific purpose. See 8 U.S.C. § 1101(a)(15).
Alien Paroled into the United States For Less Than One Year (8 U.S.C. § 1621(a)(3))
☐ 10. An alien paroled into the United States for less than one year under Section 212(d)(5) of the INA
Other Persons (8 U.S.C. § 1621(c)(2)(A) and (C))
☐ 11. A nonimmigrant whose visa for entry is related to employment in the United States, or
☐ 12. A citizen of a freely associated state, if section 141 of the applicable compact of free association approved in
Public Law 99-239 or 99-658 (or a successor provision) is in effect [Freely Associated States include the
Republic of the Marshall Islands, Republic of Palau and the Federate States of Micronesia, 48 U.S.C. § 1901 et
seq.];
☐ 13. A foreign national not physically present in the United States.
Otherwise Lawfully Present (A.R.S. § 41-1080)
☐ 14. A person not described in categories 1–13 who is otherwise lawfully present in the United States.
PLEASE NOTE: The federal Personal Responsibility and Work Opportunity Reconciliation Act may
make persons who fall into this category ineligible for licensure. See 8 U.S.C. § 1621(a).
Arizona Board of Behavioral Health Examiners (“Board”) licensure application Name: ___________________________________
LCSW application – 10/2021
Page 4 of 14
PART III. EDUCATION INFORMATION
Starting with your undergraduate education, list all colleges and universities attended, whether completed or not, in
chronological order.
C
OLLEGE OR
U
NIVERSITY
(undergraduate and graduate)
L
OCATION
(City, State or Country)
D
ATES
A
TTENDED
(Month/Yr to Month/Yr)
D
EGREE
E
ARNED
(and date earned)
M
AJOR
PART III, Section 1. OFFICIAL TRANSCRIPTS
You m
ust include an official transcript for the education being submitted to meet requirements in a SEALED envelope
from the educational institution.* Transcripts submitted in open envelopes will not be accepted. If the institution provides
certified electronic transcripts, please have them emailed to applications@azbbhe.us
.
*N
OTE: LCSW applicants with a LMSW license issued by the Board do not need to submit another transcript.
A. REQUIRED DEGREE CREDIT HOURS
Complete for the highest level of social work degree you hold (a minimum of a master degree is required).
College or University: __________________________________________
Degree Title (as indicated on transcript): ______________________________
Date degree awarded: ___________________________
B. ACCRE
DITATION OF SOCIAL WORK PROGRAM
NOTE: Complete for the social work degree listed above.
Please select one of the following:
☐ 1. The social work program I completed was accredited by the Council on Social Work Education (CSWE) on the
date my degree was awarded.
☐ 2. The social work program I completed was NOT accredited by CSWE on the date my degree was awarded.
What
is the accreditation date for the designation indicated in (B)(1) above?__________________
AP
PLICANTS SELECTING (B)(1) ABOVE PROCEED TO PART IV - BACKGROUND INFO.
FOR APPLICANTS SELECTING (B)(2), YOUR EDUCATION DOES NOT MEET THE CURRICULUM
REQUIREMENTS PURSUANT TO A.A.C. R4-6-401 AND YOU ARE NOT ELIGIBLE FOR SOCIAL
WORK LICENSURE.
Arizona Board of Behavioral Health Examiners (“Board”) licensure application Name: _____________________________________
LCSW application – 10/2021
Page 5 of 14
PART IV. BACKGROUND QUESTIONNAIRE
If the answer to any of the questions below is “YES”, provide a complete explanation below.
QUESTIONS
1.
Have you ever been denied a license, certificate, registration or membership by any state regulatory
board, any professional or occupational credentialing authority or any professional association in
Arizona or any other state?
☐ YES ☐ NO
2.
Other than complaints filed by this Board, have you ever been or are you currently the subject of any
complaint, investigation or disciplinary action against your license, certificate, registration or
membership by any state regulatory board, any professional or occupational credentialing authority
or any professional association in Arizona or any other state? If yes, please provide copies of the
complaint and all final actions.
☐ YES ☐ NO
3.
Have you ever voluntarily surrendered, allowed to lapse, canceled or resigned your license,
certificate, registration or membership in lieu of disciplinary proceedings or sanctions of any kind by
any state regulatory board, any professional or occupational credentialing authority or any
professional association in Arizona or any other state?
☐ YES ☐ NO
4.
Have you ever been arrested, charged with, convicted of or pled nolo contendere to a criminal
offense, other than a minor traffic violation (DUI history must be reported), in any city, county, state,
federal or tribal court, or in any other country? If yes, please provide copies of the police and court
documents such as the police narrative, complaint, the pleadings and final order(s). You must
answer “yes” even if you received a pardon, the charges were dropped, the conviction was set
aside, the records were expunged, or your civil rights were restored.
☐ YES ☐ NO
5.
Have you ever entered into any type of pretrial diversion or deferred prosecution agreement with a
state or federal government? If yes, please provide a copy of your pretrial diversion agreement.
☐ YES ☐ NO
6.
Have you ever been or are you currently a defendant in any type of civil or criminal action related to
any professional services (i.e., malpractice)? If so, indicate whether you entered into a settlement
agreement or were ordered to pay damages and whether such a suit is currently pending. Provide
copies of the original complaint and response, any judgment entered and any settlement agreements.
☐ YES ☐ NO
7.
Have you ever had any disciplinary action or sanctions of any kind taken against you by any
behavioral health related employer in Arizona or any other state? If yes, please provide the name,
address and telephone number of the employer, the name of your immediate supervisor and a
description of the cause for disciplinary action or sanction.
☐ YES ☐ NO
8.
Have you ever been involuntarily terminated or resigned in lieu of termination from any behavioral
health position or related employment? If yes, please provide the name, address and telephone
number of the employer, the name of your immediate supervisor and a description of the cause for
the termination. If the cause of termination was due to a reduction in force, please include a copy of
the letter advising you of the layoff.
☐ YES ☐ NO
CONFIDENTIAL QUESTION
9.
Have you received treatment within the last five years for use of alcohol or a controlled substance,
prescription-only drug, or dangerous drug or narcotic, or a physical, mental, emotional, or nervous
disorder or condition that currently affects your ability to competently and safely perform the
essential functions of your profession? If so, provide the following:
a. A detailed description of the use, disorder, or condition; and
b. An explanation of whether the use, disorder, or condition is reduced or ameliorated because
you’re receiving ongoing treatment and if so, the name and contact information for all current
treatment providers and for all monitoring or support programs in which you are currently
participating.
c. A copy of any public or confidential agreement or order relating to the use, disorder, or
condition, issued by a licensing agency or health care institution within the last five years, if
applicable.
☐ YES ☐ NO
Arizona Board of Behavioral Health Examiners (“Board”) licensure application Name: _____________________________________
LCSW application – 10/2021
Page 6 of 14
PART IV. BACKGROUND QUESTIONNAIRE – (cont’d)
Use the space below to provide a complete explanation for any “YES” answers above. Use additional paper if
necessary, and include copies of relevant documents, including court and/or regulatory agency documents
showing the disposition of disciplinary and court-related matters.
Arizona Board of Behavioral Health Examiners (“Board”) licensure application Name: _____________________________________
LCSW application – 10/2021
Page 7 of 14
PART V. EMPLOYMENT HISTORY
Provide all employment for the previous seven years. Copy sheet as needed. IMPORTANT: include an explanation of any
breaks in employment of greater than one month. If you hold an LMSW from the Board, provide the work history since
submission of your LMSW application.
PRESENT
EMPLOYMENT
J
OB
T
ITLE
MM
/
DD
/
YY TO MM
/
DD
/
YY
N
AME OF
B
USINESS OR
I
NSTITUTION
(A
GENCY OR
O
RGANIZATION
)
☐
E
MPLOYEE ☐
I
NDEPENDENT
C
ONTRACTOR ☐
O
THER
________________
A
DDRESS
C
ITY
,
S
TATE
,
Z
IP
T
ELEPHONE
N
AME AND
T
ITLE OF SUPERVISOR
D
ESCRIPTION OF DUTIES PERFORMED
R
EASON FOR
LEAVING:
☐
R
ESIGNED
–
NEW POSITION
☐
R
ESIGNATION
–
O
THER
(
EXPLAIN
)
☐
T
ERMINATION
(
EXPLAIN
)
☐
R
ESIGNED IN LIEU OF TERMINATION
(
EXPLAIN
)
PRIOR
EMPLOYMENT
J
OB
T
ITLE
MM
/
DD
/
YY TO MM
/
DD
/
YY
N
AME OF
B
USINESS OR
I
NSTITUTION
(A
GENCY OR
O
RGANIZATION
)
☐
E
MPLOYEE ☐
I
NDEPENDENT
C
ONTRACTOR ☐
O
THER
________________
A
DDRESS
C
ITY
,
S
TATE
,
Z
IP
T
ELEPHONE
N
AME AND
T
ITLE OF SUPERVISOR
D
ESCRIPTION OF DUTIES PERFORMED
R
EASON FOR
LEAVING:
☐
R
ESIGNED
–
NEW POSITION
☐
R
ESIGNATION
–
O
THER
(
EXPLAIN
)
☐
T
ERMINATION
(
EXPLAIN
)
☐
R
ESIGNED IN LIEU OF TERMINATION
(
EXPLAIN
)
PRIOR
EMPLOYMENT
J
OB
T
ITLE
MM
/
DD
/
YY TO MM
/
DD
/
YY
N
AME OF
B
USINESS OR
I
NSTITUTION
(A
GENCY OR
O
RGANIZATION
)
☐
E
MPLOYEE ☐
I
NDEPENDENT
C
ONTRACTOR ☐
O
THER
________________
A
DDRESS
C
ITY
,
S
TATE
,
Z
IP
T
ELEPHONE
N
AME AND
T
ITLE OF SUPERVISOR
D
ESCRIPTION OF DUTIES PERFORMED
R
EASON FOR
LEAVING:
☐
R
ESIGNED
–
NEW POSITION
☐
R
ESIGNATION
–
O
THER
(
EXPLAIN
)
☐
T
ERMINATION
(
EXPLAIN
)
☐
R
ESIGNED IN LIEU OF TERMINATION
(
EXPLAIN
)
Arizona Board of Behavioral Health Examiners (“Board”) licensure application Name: _____________________________________
LCSW application – 10/2021
Page 8 of 14
PART V. EMPLOYMENT HISTORY (cont’d)
Provide all employment for the previous seven years. Copy sheet as needed. IMPORTANT: include an explanation of any
breaks in employment of greater than one month. If you hold an LMSW from the Board, provide the work history since
submission of your LMSW application.
PRESENT
EMPLOYMENT
J
OB
T
ITLE
MM
/
DD
/
YY TO MM
/
DD
/
YY
N
AME OF
B
USINESS OR
I
NSTITUTION
(A
GENCY OR
O
RGANIZATION
)
☐
E
MPLOYEE ☐
I
NDEPENDENT
C
ONTRACTOR ☐
O
THER
________________
A
DDRESS
C
ITY
,
S
TATE
,
Z
IP
T
ELEPHONE
N
AME AND
T
ITLE OF SUPERVISOR
D
ESCRIPTION OF DUTIES PERFORMED
R
EASON FOR
LEAVING:
☐
R
ESIGNED
–
NEW POSITION
☐
R
ESIGNATION
–
O
THER
(
EXPLAIN
)
☐
T
ERMINATION
(
EXPLAIN
)
☐
R
ESIGNED IN LIEU OF TERMINATION
(
EXPLAIN
)
PRIOR
EMPLOYMENT
J
OB
T
ITLE
MM
/
DD
/
YY TO MM
/
DD
/
YY
N
AME OF
B
USINESS OR
I
NSTITUTION
(A
GENCY OR
O
RGANIZATION
)
☐
E
MPLOYEE ☐
I
NDEPENDENT
C
ONTRACTOR ☐
O
THER
________________
A
DDRESS
C
ITY
,
S
TATE
,
Z
IP
T
ELEPHONE
N
AME AND
T
ITLE OF SUPERVISOR
D
ESCRIPTION OF DUTIES PERFORMED
R
EASON FOR
LEAVING:
☐
R
ESIGNED
–
NEW POSITION
☐
R
ESIGNATION
–
O
THER
(
EXPLAIN
)
☐
T
ERMINATION
(
EXPLAIN
)
☐
R
ESIGNED IN LIEU OF TERMINATION
(
EXPLAIN
)
PLEA
SE USE THE SPACE BELOW TO EXPLAIN GAPS IN EMPLOYMENT OF
GREATER THAN A MONTH:
Arizona Board of Behavioral Health Examiners (“Board”) licensure application Name: _____________________________________
PART VI. WORK EXPERIENCE AND CLINICAL SUPERVISION
APPLICANT: To meet the requirements for independent licensure, a minimum of two years of supervised work
experience and clinical supervision meeting the Board’s rules must be verified. For more information on
acquiring supervised work experience and clinical supervision, click here. It is an applicant’s responsibility to
request that Employers or Supervisors complete the required forms to verify supervised work experience and/or
clinical supervision.
• Verification of Supervised Work Experience – This form must be completed by an employer or direct
supervisor from any employment that you are using to meet the requirements for licensure purposes. For
the hours of supervised work experience to be considered, you must have been receiving clinical supervision
that meets the requirements in Board rule for the entire period. There should be ONE form (per employer)
for the entire period of your supervised work experience. NOTE: A Clinical Supervisor who was hired
outside the Agency to provide supervision cannot complete this form unless they were pre-approved by the
Board for Supervised Private Practice.
• Verification of Clinical Supervision – This form must be completed by the Clinical Supervisor(s) who
provided individual and/or group clinical supervision during the period of supervised work experience being
submitted for licensure purposes. NOTE: The Board cannot accept hours of clinical supervision from more
than six Clinical Supervisors.
CLINICAL SUPERVISOR EXEMPTION REQUESTS
Please review the applicable rules for the requirements for acceptable hours of clinical supervision for clinical
social worker licensure.
If the Clinical Supervisor who will provide or who provided the clinical supervision does not meet the
requirements in A.A.C. R4-6-404 (B)(1-2), you may be able to request an exemption pursuant to A.A.C. R4-6-
212.01.
Review the Clinical Supervisor Exemption Request form on the Board’s website. The form can be submitted at
any point during the supervision, but it is HIGHLY recommended to submit the form PRIOR to beginning
supervision to prevent losing supervised work experience and clinical supervision hours if the Clinical Supervisor
Exemption request is not approved.
Have you previously submitted a Clinical Supervisor Exemption Request? ☐ YES ☐ NO
If YES and it was approved, please include a copy of the letter approving the request.
LCSW application – 10/2021
Page 9 of 14
Arizona Board of Behavioral Health Examiners (“Board”) licensure application Name: _____________________________________
LCSW application – 10/2021
Page 10 of 14
PART VI. WORK EXPERIENCE AND CLINICAL SUPERVISION (cont’d)
THERE ARE TWO OPTIONS FOR EMPLOYER(S) and/or SUPERVISOR(S) TO SUBMIT FORMS:
Option 1 – ONLINE SUBMISSION: appropriate if the applicant has already submitted their application or will
be submitting their application within 3 months. The Board will not hold forms for more than 3 months.
Employer(s) and/or Supervisor(s) can complete the form(s) online by:
a. Going to the Board’s website, https://www.azbbhe.us
b. Clicking on Applying for Licensure and choosing the appropriate discipline
c. Clicking on Submit Online in the supervision forms and attaching any required documents
Option 2 – PRINT PDF: preferred if the supervisee’s application date is unknown. The supervisee will be
responsible for maintaining the signed, sealed envelopes until they submit their application.
Employer(s) and/or Supervisor(s) can complete the paper form(s) by:
a. Going to the Board’s website, https://www.azbbhe.us
b. Clicking on Applying for Licensure and choosing the appropriate discipline
c. Clicking on Print PDF, completing the fillable form and attaching any required documentation
d. Put the completed form(s) in a sealed envelope
e. Sign over the seal and give to the supervisee for submission with their application
APPLICANT: Please complete the grid below by listing any Employers or Supervisors who are completing
verification forms and the method of submission (emailed or attached in a sealed envelope).
V
ERIFICATION OF
S
UPERVISED
W
ORK
E
XPERIENCE
FORMS (ENTER EMPLOYER/SUPERVISOR NAME BELOW)
E
MAILED OR
ATTACHED
V
ERIFICATION OF
C
LINICAL
S
UPERVISION FORMS
(ENTER CLINICAL SUPERVISOR NAME BELOW)
E
MAILED OR
ATTACHED
Arizona Board of Behavioral Health Examiners (“Board”) licensure application Name: _____________________________________
LCSW application – 10/2021
Page 11 of 14
PART VII. EXAM INFORMATION
Ha
ve you previously passed the examination required for the license you are applying for in Arizona? ☐ Yes ☐ No
• If yes, you must request that an official copy of your score report be sent to the Board directly from ASWB.
• If not, you will be provided testing information once authorized to test.
For information on obtaining special examination accommodations under the Americans with Disabilities Act (ADA),
please visit https://www.aswb.org/exam-candidates/testing-accommodations/
or contact ASWB’s Candidate Services at
(888) 579-3926 or General Information at (800) 225-6880.
PART VIII. FEDERAL DATA BANK SELF-QUERY
To m
eet the requirements of A.A.C. R4-6-301(11), the Board will perform a query of the applicant’s data in the
National
Practitioner Data Bank (NPDB).
PART IX. PROFESSIONAL CREDENTIALS
Please list current or previous licenses or certifications issued by a state regulatory entity held as follows: any license or
certification ever held in the practice of behavioral health; and any professional license or certification NOT in the practice
of behavioral health held in the last ten years. Failure to disclose all licenses, certifications or registrations as required
above may result in denial of your application or other appropriate action. Do not list licenses issued by the Board.
Title of Credential Held
State
Date Issued
Expiration Date
Credential #
Current Status
For all credentials listed above, attach a verification from the regulatory entity issuing the credential. The verification must
include the following information:
• Professional’s name
• Credential title and number (if applicable)
• Credential issue and expiration date
• Credential status
• Whether there are pending complaints
• Past disciplinary actions
Applicants may use an online verification if it contains all required items above. If not, applicant must obtain verification
from the regulatory entity issuing the credential. A copy of your wall certificate is NOT sufficient.
Arizona Board of Behavioral Health Examiners (“Board”) licensure application Name: _____________________________________
LCSW application – 10/2021
Page 12 of 14
PART X. CRIMINAL HISTORY BACKGROUND CHECK
Purs
uant to A.R.S. § 32-3280, all applicants for licensure must submit a full set of fingerprints and payment for a criminal
history background check through the Arizona Department of Public Safety (“DPS”) unless they can provide verification
that they hold a current, valid DPS fingerprint clearance card. Please select one of the following:
☐ I have attached a set of fingerprints on a FD-258 card and a payment of $40.00 or verification of my online
credit card payment of $40.00.
☐ I
hold another license with the Board and submitted a full set of fingerprints with my previous application.
☐ I hold a valid DPS fingerprint clearance card # _____________________ and have attached a verification
from the DPS website https://webapps.azdps.gov/public_inq_acct/acct/ShowClearanceCardStatus.action
.
If
you are submitting a set of fingerprints, they will be sent to DPS for a criminal history background check which can take
2-6 weeks.
PART XI. CERTIFYING STATEMENT
I gi
ve my permission for the Arizona Board of Behavioral Health Examiners (“Board”) to secure additional information
concerning me or my statements in this application from any person or source the Board deems necessary. My signature
below authorizes entities in possession of applicable information to release such information to the Board.
I w
ill notify the Board in writing within 10 working days if charged with a misdemeanor that may affect patient safety or a
felony pursuant to A.R.S. § 32-3208. Additionally, I will report to the Board any updates to the information provided in
this application after submission including, but not limited to: contact information, employment changes, and answers to
background information questions.
I ce
rtify that by submitting this application for licensure, I have read and understand the Board’s rules and statutes and agree
to abide by them as an applicant and as a licensee in the event I am approved for licensure.
I, ____________
_________________certify under penalty of perjury that all information contained in my application,
including all supporting documents, is true and correct to the best of my knowledge and belief, and with full knowledge that
any false statements or misrepresentations made in this application may be grounds for refusal, subsequent revocation or
suspension of my license(s), or other disciplinary action.
Signature of Applicant
Date
LCSW application – 10/2021
Page 13 of 14
IS MY APPLICATION READY TO SUBMIT?
I HAVE INCLUDED ALL OF THE FOLLOWING DOCUMENTS:
☐ A copy of my driver’s license or state-issued ID (for current legal name verification)
☐ Documentation of legal authorized presence to reside and seek employment in the US (from pg 3 – a driver’s
license issued by a state that verifies lawful presence in the US provides acceptable proof)
☐ A complete set of fingerprints on a standard FD-258 card with a $40.00 payment (if fingerprints were not
previously submitted with another application), OR a copy of my current DPS fingerprint clearance card (front
and back) and verification from the DPS website
. NO PAYMENT is needed with a current DPS fingerprint
clearance card.
☐ An official transcript in a sealed envelope (not needed if previously submitted with your LMSW application to
the Board). If requesting electronic transcripts, please have the institution email them to
applications@azbbhe.us.
☐ Verification of professional credentials
☐ Verification(s) of supervised work experience emailed by the supervisor/employer or in a sealed envelope with
job description included
☐ Verification(s) of clinical supervision hours emailed by the clinical supervisor(s) or in a sealed envelope
☐ Clinical Supervisor Exemption Request (if applicable)
☐ Verification of supervisor’s credentials (if applicable)
☐ Employment history for previous SEVEN years including an explanation of any gaps in employment of greater
than one month
☐ FEES: Applicable fees may be paid by credit card on the Board’s website by clicking on “Make a Payment
”, or
through money order or cashier’s check (NO PERSONAL OR BUSINESS CHECKS accepted) made out to
“Arizona Board of Behavioral Health Examiners” or “AZBBHE” by mail, including:
$250.00 non-refundable application fee
$ 40.00 payment for processing fingerprints if mailing a FD-258 card
Fees may be combined into one payment.
SUBMIT TO: Arizona Board of Behavioral Health Examiners
1740 West Adams St., Suite 3600
Phoenix, Arizona 85007
Office Hours: Monday – Friday 8:00 am to 5:00 pm, excluding state holidays
FOLLOWING SUBMISSION:
• Confirm receipt of the application on the Board’s website by:
o Clicking on “Verifications,” then “Check for pending applications
”
o Search by your last name. Your application will display as “Pending” if received
• Staff will email you updates on the progress of your application including when your application is
administratively and substantively complete, if additional information is needed, and next steps in the process
• Staff will email you regarding any Committee or Board meetings at which your application will be reviewed
• If applicable, staff will provide information on taking an exam required for licensure
• You must notify the Board if any information provided in the application changes including, but not limited to:
o Contact information
o Employment changes
o Answers to background information questions.
• You must notify the Board in writing within 10 working days if charged with a misdemeanor that may affect
patient safety or a felony pursuant to A.R.S. § 32-3208
FOR INFORMATIONAL PURPOSES ONLY. DO NOT SUBMIT WITH YOUR APPLICATION.
LCSW ap
plication – 10/2021
Page 14 of 14
FOR INFORMATIONAL PURPOSES ONLY. DO NOT SUBMIT WITH YOUR APPLICATION.
Pursuant to A.R.S. §§ 41-1030, 41-1093.05, the following information must accompany all
license applications.
41-1030. Invalidity of rules not made according to this chapter; prohibited agency action;
prohibited acts by state employees; enforcement; notice
A. A rule is invalid unless it is made and approved in substantial compliance with sections 41-1021 through
41-1029 and articles 4, 4.1 and 5 of this chapter, unless otherwise provided by law.
B. An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that
is not specifically authorized by statute, rule or state tribal gaming compact. A general grant of authority in
statute does not constitute a basis for imposing a licensing requirement or condition unless a rule is made
pursuant to that general grant of authority that specifically authorizes the requirement or condition.
C. An agency shall not:
1. Make a rule under a specific grant of rulemaking authority that exceeds the subject matter areas listed in
the specific statute authorizing the rule.
2. Make a rule under a general grant of rulemaking authority to supplement a more specific grant of
rulemaking authority.
D. This section may be enforced in a private civil action and relief may be awarded against the state. The court
may award reasonable attorney fees, damages and all fees associated with the license application to a party
that prevails in an action against the state for a violation of this section.
E. A state employee may not intentionally or knowingly violate this section. A violation of this section is cause
for disciplinary action or dismissal pursuant to the Agency's adopted personnel policy.
F. This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.
G. An agency shall prominently print the provisions of subsections B, D, E and F of this section on all license
applications, except license applications processed by the corporation commission.
H. The licensing application may be in either print or electronic format.
41-1093.05. License Applicants; notice
Pursuant to section 41-1093.01, Arizona Revised Statutes, an agency shall limit all occupational regulations to
regulations that are demonstrated to be necessary to specifically fulfill a public health, safety or welfare
concern. Pursuant to sections 41-1093.02 and 41-1093.03, Arizona Revised Statutes, you have the right to
petition this agency to repeal or modify the occupational regulation or bring an action in a court of general
jurisdiction to challenge the occupational regulation and to ensure compliance with section 41-1093.01, Arizona
Revised Statutes.
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STATE OF ARIZONA BOARD OF BEHAVIORAL HEALTH EXAMINERS

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Completed 18 May 2022

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