Looking for a New York State Legal Forms And Templates? Download it for free!

Section II: Supervisor's Verification of Plan for Experience (continued)

Attestation

I hereby certify that I have read Appendix A and that I meet the requirements to supervise experience for LCSW’s. I understand that the

above information will be used to review the plan for supervised experience of the LCSW seeking the LCSW Psychotherapy “R” Privilege

and that the answers given are truthful and accurate to the best of my ability. This form must be signed and dated in the presence of a

Notary Public.

Signature: _________________________________________________________________________ Date: _______ / _______ / _______

mo.

day

yr.

Print name : _______________________________________________________________________

Address: __________________________________________________________________________

__________________________________________________________________________

Phone: ____________________________________ Fax: ___________________________________

E-mail: ____________________________________________________________________________

If the supervisor is not an employee of the same agency as the applicant, please provide information about the applicant’s employer:

Name of Agency/Employer: ____________________________________________________________

(Where supervised experience took place)

Agency Address: ____________________________________________________________________

____________________________________________________________________

Phone: ____________________________________ Fax: ___________________________________

E-mail: ____________________________________________________________________________

The patient will be notified that the agency has authorized a third-party supervisor with access to the patient’s records.

Name of Agency Representative: _______________________________________________________

Signature: _________________________________________________________________________ Date: _______ / _______ / _______

mo.

day

yr.

Print name: ________________________________________________________________________

Notary

State of __________________________________________________ County of _____________________________________________

On the _______________ day of ______________________ in the year _____________ before me, the above signed, personally appeared

___________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose

name is subscribed to this application and acknowledged to me that he/she executed the application and swore that the statements made by

him/her in the application and all supporting materials are true, complete, and correct.

Notary Public signature _________________________________________________________________________________________

Notary ID number _______________________________

Notary Stamp

Expiration date __________ / __________ / __________

Month

Day

Year

Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,

New York State Board for Social Work, 89 Washington Avenue, Albany, NY 12234-1000

Licensed Clinical Social Worker Psychotherapy “R” Privilege Form 6SWPR, Page 3 of 3, Rev. 11/15

Licensed Clinical Social Worker Psychotherapy "R" Privilege Form 6swpr - Plan For Post-Lcsw Supervised Experience Page 3

Related Articles

Related forms

Related Categories