Licensed Master Social Worker Form 4q - Approval Of Qualifications To Supervise Psychotherapy
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1
2
3The University of the State of New York
Licensed Master
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Social Worker Form 4Q
Division of Professional Licensing Services
Approval of Qualifications to Supervise Psychotherapy
Applicant Instructions
Note: A supervisor who is not licensed in New York State or has not previously been approved by the State Education Department
to supervise LMSW’s who provide psychotherapy services must complete this form.
Complete Section I and forward the entire form to the supervisor (LCSW, psychiatrist, or psychologist) who supervised your work
experience. Ask the supervisor to complete Section II and send the entire form directly to the Office of the Professions at the address at the
end of the form. This form will not be accepted if submitted by the applicant.
This form may be submitted prior to the experience to confirm the eligibility of the supervisor.
Section I: To be Completed by the Applicant
1.
1
Print Name as It Appears on Your Application for Licensure (Form 1)
2
Social Security Number
(Leave this blank if you do not have
Last
a U.S. Social Security Number)
First
Middle
2.
3
New York State Licensed Master Social Worker License Number:
3.
Supervisor’s Name
4
_____________________________________________ _________________________________ ____________________________
Last
First
Middle
Section II: To be Completed by the Supervisor
Complete this section and return all pages of this form to the Office of the Professions at the address at the end of the form. Your
signature on this form must be notarized by a Notary Public.
1.
Were you licensed and registered in the State of New York at the time you supervised the applicant?
Yes
No
1
a.
N.Y.S. License number:
Date license issued
Month
Day
Year
Profession: __________________________________________________
b.
Other State licenses:
Profession
State
License Number
Date of License
c.
Check degree:
Ph.D./DSW
Ed.D.
Psy.D.
M.S.W.
M.D.
d.
Title of degree: ____________________________________________________________________________________________
e.
Date of receipt of degree: _______________________________________________
Name of school: ___________________________________________________________________________________________
f.
Board certification?
No
Yes
If yes, title of certification: ________________________________________________
Licensed Master Social Worker Form 4Q, Page 1 of 3, Rev. 11/15
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