Clinical Social Worker Experience Verification Form

Download a blank fillable Clinical Social Worker Experience Verification Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Clinical Social Worker Experience Verification Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

STATE OF CALIFORNIA - BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY
Governor Edmund G. Brown Jr.
Board of Behavioral Sciences
1625 North Market Blvd., Suite S200, Sacramento, CA 95834
Telephone: (916) 574-7830 TTY: (800) 326-2297
CLINICAL SOCIAL WORKER
EXPERIENCE VERIFICATION
Your supervisor must complete this form as follows:
o Use a separate form for each supervisor and
o Provide an original signature in ink and have
employer
the signer initial any changes
o Make sure this form is complete and correct prior
o All information on this form is subject to
to signing
verification
APPLICANT NAME: _________________________________________ ASW#: ________________
APPLICANT’S EMPLOYER INFORMATION
Applicant’s Employer’s Name:
Business Telephone
Address:
Number and Street
City
State
Zip Code
1. Did this setting lawfully and regularly provide clinical social work, mental health counseling or
psychotherapy?
Yes
No
2. Did this setting provide oversight to ensure the ASW’s work meets experience requirements and is within the
scope of practice?
Yes
No
EXPERIENCE INFORMATION:
Dates of experience: From ___________ to ___________
(mm/dd/yyyy)
(mm/dd/yyyy)
1. Total supervised weeks: (minimum 104):
2. Total hours in individual supervision (minimum 52):
3. Total hours in group supervision:
4. Average hours worked per week (max 40):
A.
5. Total hours in clinical psychosocial diagnosis, assessment, and treatment, including
individual or group psychotherapy / counseling: (minimum 2,000):
6. Of the above hours, how many were gained performing face-to-face individual or group
psychotherapy/counseling: (minimum 750):
7. Total hours in client-centered advocacy, consultation, evaluation & research: (max 1,200):
B.
8. Total hours of experience: (minimum 3,200):
(A + B = C)
C.
9. Was one additional hour of face-to-face individual or two hours of face-to-face group supervision given for every
week in which more than 10 hours of face-to-face psychotherapy was performed?
Yes
No
37A-201 (Rev. 04/2015)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2