Clinical Social Worker In-State Experience Verification Form
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2STATE 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
IN-STATE EXPERIENCE VERIFICATION
Have your supervisor complete this form as follows:
o Use a separate form for each supervisor
o Provide an original signature in ink and have
and employer
the signer initial any changes
o Make sure this form is complete and
o Submit with your Application for Licensure
and Examination
correct prior to signing
APPLICANT NAME: ___________________________________ ASW Number: ___________
APPLICANT’S EMPLOYER INFORMATION
Name of Applicant’s Employer:
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 met the experience requirements and
was within the scope of practice?
Yes
No
SUPERVISOR INFORMATION
Supervisor’s Name
Telephone
Email Address (OPTIONAL)
License Type
License Number
State
Date First Licensed
If a physician, were you certified in Psychiatry by the American Board of Psychiatry and Neurology during
the entire period of supervision?
Yes
No
N/A
If YES, provide certificate number:_________________
37A-201 (Revised 01/2017)
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