Licensed Clinical Social Worker Psychotherapy "R" Privilege Form 6swpr - Plan For Post-Lcsw Supervised Experience
ADVERTISEMENT
1
2
3The University of the State of New York
Licensed Clinical Social
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Worker Psychotherapy “R”
Division of Professional Licensing Services
Privilege Form 6SWPR
Plan for Post-LCSW Supervised Experience
Applicant Instructions
1.
Complete Section I. In item 3, enter your name exactly as it appears on your Application for Licensed Clinical Social Worker
Psychotherapy “R” Privilege (Form 1SWPR). Be sure to sign and date item 7. Use the psychotherapy log to document your hours of
practice and supervision.
2.
Send the entire form along with a copy of Appendix A to your supervisor and ask him/her to complete Section II and forward the entire
form directly to the Office of the Professions at the address at the end of this form. This form will not be accepted if submitted by
the applicant.
Section I: Applicant Information
2
1.
Social Security Number
2. Birth Date
Month
Day
Year
1
(Leave this blank if you do not have a U.S. Social Security Number)
3.
3
Print Name as It Appears on Your Application for Licensure (Form 1)
5
6.
Telephone/E-Mail Address
Last
Daytime phone
First
Area Code
Phone
Middle
E-mail Address
(please print clearly)
4
4.
Mailing Address
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
6.
You must complete 2400 client contact hours of post-LCSW experience in psychotherapy over a period of at least 36 months with a
6
minimum of 400 client hours per year. You must have been supervised by a licensed clinical social worker with the “R” privilege,
licensed psychologist or physician who meets the requirements of section 74.5 of the Commissioner’s Regulations in an acceptable
setting as defined in section 74.5.
Name of proposed clinical supervisor: ______________________________________________________________________________
Name of setting: _______________________________________________________________________________________________
Setting address: _______________________________________________________________________________________________
LCSW License Number:
Date LCSW License issued: Month
Day
Year
. Attestation
10
7
I declare and affirm that the statements made in the foregoing application, including accompanying statements are true, complete and
correct. I understand that any false or misleading information in, or in connection with my application may be cause for denial of
qualification and may lead to a filing of charges of professional misconduct.
_________________________________________________________________________________________ ________ / ________ / ________
Applicant’s Signature
mo.
day
yr.
Licensed Clinical Social Worker Psychotherapy “R” Privilege Form 6SWPR, Page 1 of 3, Rev. 11/15
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 4swpr - Certification Of Experience For Licensed Clinical Social Worker Psychotherapy "r" Privilege
Legal
Licensed Master Social Worker Form 4q - Approval Of Qualifications To Supervise Psychotherapy
Business
Licensed Master/social Worker - Application For Licensure - The University Of The State Of New York The State Education Department - 2016
Legal
Related Categories
Parent category: Legal