Licensed Clinical Social Worker Psychotherapy "R" Privilege Form 6swpr - Plan For Post-Lcsw Supervised Experience Page 2
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2
3Section II: Supervisor's Verification of Plan for Experience
Instructions For Completing Section II: Please complete Section II, be sure to sign the affidavit, have your signature notarized by a
Notary Public and return 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 returned by the applicant. By completing Section II, the supervisor is certifying that the person named in Section I will receive
supervision that meets the requirements specified in Education Law and the Commissioner's Regulations.
1.
Name of applicant: _____________________________________________________________________________________________
(Item 3 on page 1)
2.
Name of supervisor: ____________________________________________________________________________________________
(Supervisor must complete Form 4Q if not already approved by Department)
Title: ________________________________________________________________________________________________________
(attach copy of supervisor’s license)
Setting where the applicant will provide diagnosis and psychotherapy services under your supervision:
Name of facility or private practice: ____________________________________________________________________________________
Address: _________________________________________________________________________________________________________
The facility is a (check one and attach copy of authorization to provide services):
Private practice owned by LCSW (the applicant)
Private practice owned by supervisor (LCSW-R, Licensed psychologist or psychiatrist)
Professional entity (PLLC, PLLP, P.C.) owned by supervisor (attached consent from SED)
Sole proprietorship or other entity authorized under law (attach certificate of corporation)
Program approved by the New York State Office of Mental Health (OMH), Office for People with Developmental Disabilities (OPWDD),
Office of Alcoholism & Substance Abuse Services (OASAS), Office of Children & Family Services (OCFS), Department of Correctional
Services, State Office for the Aging, or local social service or mental hygiene district (attach operating certificate)
Not-for-Profit or educational corporation authorized by a waiver issued by the State Education Department. (Attach copy of
authorization.)
Enrollment in a psychotherapy program in an institution of higher education, psychotherapy institute chartered by Board of Regents and
authorized to provide psychotherapy to the public (attach copy of Regents Charter)
Elementary, middle, high school or college authorized to provide psychotherapy services to students (attach copy of authorization)
Other entity authorized under law to employ licensed professionals and provide services. (Attach copy of certificate of incorporation)
Supervisor:
Education Law and Commissioner’s Regulations define acceptable experience as 2400 client contact hours in psychotherapy. The
supervisor is responsible for the assessment, evaluation and treatment of patients seen by the applicant and for delegating to the applicant
those activities he/she is competent to perform. Failure to provide appropriate supervision could result in charges of unprofessional conduct
against the licensed supervisor. A record of client contact hours and supervision hours will be completed and retained by the supervisor who
is responsible for submitting verification of the supervised experience.
I am a (check all that apply):
Licensed Clinical Social Worker
License number: ____________________
License date: _______ / _______ / _______
mo.
day
yr.
Licensed Psychologist
License number: ____________________
License date: _______ / _______ / _______
mo.
day
yr.
Licensed Physician
License number: ____________________
License date: _______ / _______ / _______
mo.
day
yr.
Do you have Board certification in psychiatry?
Yes
No
Licensed Clinical Social Worker Psychotherapy “R” Privilege Form 6SWPR, Page 2 of 3, Rev. 11/15
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