37a-209 - Asw Weekly Tracking Log printable pdf download

37a-209 - Asw Weekly Tracking Log

BOARD OF BEHAVIORAL SCIENCES

STATE OF CALIFORNIA

1625 NORTH MARKET BLVD., SUITE S200, SACRAMENTO, CA 95834

ASW WEEKLY TRACKING LOG

TELEPHONE: (916) 574-7830 TTY: (800) 326-2297

37A-209 (

. 01/11)

REV

WEB SITE ADDRESS

NOTE: THIS FORM IS ONLY A TRACKING RESOURCE AND IS NOT TO BE USED AS OFFICIAL

DOCUMENTATION OF SUPERVISED WORK EXPERIENCE. SUPERVISED WORK EXPERIENCE SHALL BE

SUBMITTED ON THE CLINICAL SOCIAL WORKER EXPERIENCE VERIFICATION FORM.

YEAR _______________

Name of Associate Clinical Social Worker: _______________________________________________________

Name of Supervisor: ____________________________ ____________________________________________

Work Setting: ______________________________________________________________________________

Name and Address of Employer

Total

WEEK OF:

Hours

A. Clinical Psychosocial Diagnosis,

Assessment, and Treatment,

including Individual or Group

Psychotherapy (min. 2,000 hours)

A1. Individual or Group

Psychotherapy * (min. 750 hours)

B. Client-centered advocacy,

consultation, evaluation, and research

(max. 1,200)

C. Total Hours Per Week (max 40 hrs

per week) (A+B = C)

Supervision, Individual Face to Face

Supervision, Group

The letters “A,” “A1,” “B,” and “C” correspond directly to the lettering system used in item 12 on the Clinical Social

Worker Experience Verification form.

* “A1” is a sub-category of “A.” This line tells you how much of “A” was Individual or Group

Psychotherapy. When totaling hours of experience do not double count these hours. Use the formula

found in box “C” to total your hours of supervised experience for the week.

This form may be reproduced

37a-209 - Asw Weekly Tracking Log