Clinical Supervision Plan Template Page 4

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CLINICAL SUPERVISION PLAN ADDENDUM
INSTRUCTIONS FOR DETAILED DESCRIPTION OF CLINICAL SOCIAL WORK PRACTICE
GENERAL INFORMATION
ONLY FOR LGSW AND LISE LICENSEES PRACTICING CLINICAL SOCIAL WORK
If you are licensed as an LGSW or LISW and are practicing social work within a clinical scope, as defined in Minnesota Statutes,
Chapter 148E.010, subdivision 6 (as noted below), you will be required to submit a Detailed Description of Clinical Social Work
Practice.
In addition, when you renew your license or when you apply for the LICSW license, your supervisor(s) must complete a
Supervision Verification form which includes an attestation that you have “demonstrated skill through practice experience in the
diagnosis, treatment, and prevention of mental and emotional disorders”.
Definition of Clinical Social Work: Minnesota Statutes, Chapter 148E.010, subdivision 6: “Clinical practice” means applying
professional social work knowledge, skills, and values in the differential diagnosis and treatment of psychosocial function,
disability, or impairment, including addictions and emotional, mental, and behavioral disorders. Treatment includes a plan
based on a differential diagnosis. Treatment may include, but is not limited to, the provision of psychotherapy to
individuals, couples, families, and groups.
INSTRUCTIONS FOR DETAILED DESCRIPTION OF CLINCIAL PRACTICE
The Detailed Description of Practice must address each of the following elements:
1. Client population and the range of presenting issues/diagnoses
2. Clinical modalities commonly utilized
3. Diagnostic process, including:
a) process utilized for determining clinical diagnoses;
b) diagnostic instruments use, and;
c) role of the licensee/applicant in the diagnostic process.
It is important to be as specific and detailed as possible.
ALL licensing supervisors must attest to the accuracy of the detailed description of practice by providing their signature and date.
When submitting verification of supervision, do not resubmit a detailed description of practice which has been previously
submitted with a Clinical Supervision Plan.
Minnesota Board of Social Work
Clinical Supervision Plan
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