Clinical Social Worker In-State Experience Verification Form Page 2
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2APPLICANT NAME: __________________________________________ ASW#: _______________
SUPERVISOR INFORMATION (continued)
Were you (the supervisor) employed by the supervisee’s employer?
Yes
No
If NO, did you and the supervisee’s employer sign a letter of agreement wherein you agreed to take
supervisory responsibility for the associate’s social work services?
Yes
No
EXPERIENCE INFORMATION:
Dates of experience: From ____________ to ____________
(mm/dd/yyyy)
(mm/dd/yyyy)
1. Total supervised weeks (Minimum 104 overall):
2. Total hours in individual supervision (Minimum 52 overall):
3. Total hours in group supervision:
4. Average hours worked per week (Maximum 40):
5. Total hours of clinical psychosocial diagnosis, assessment, and treatment, including
A.
individual or group psychotherapy / counseling (Minimum 2,000 overall):
6. Of the above hours, how many were gained performing face-to-face individual or
group psychotherapy/counseling (Minimum 750 overall):
7. Total hours of client-centered advocacy, consultation, evaluation, research,
B.
workshops, seminars, training sessions or conferences and direct supervisor contact*
(Maximum 1,200 overall):
8. Total hours of experience (Minimum 3,200 overall):
(A + B = C) C.
9. Was one (1) additional hour of face-to-face individual OR two (2) additional hours of
Yes
face-to-face group supervision provided for every week in which more than 10 hours of
No
face-to-face psychotherapy was performed?
*A maximum of six (6) hours of direct supervisor contact per week may be counted toward
the 1,200 hours.
NOTE: Knowingly providing false information or omitting pertinent information may be
grounds for denial of the application. The Board may take disciplinary action on a licensee
who helps an applicant obtain a license by fraud, deceit or misrepresentation. All information
on this form is subject to verification.
Signature of Supervisor: _____________________________________ Date: ______________
ORIGINAL SIGNATURE REQUIRED
37A-201 (Revised 01/2017)
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