Licensed Master Social Worker Form 4q - Approval Of Qualifications To Supervise Psychotherapy Page 2
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3Section II: To be Completed by the Supervisor (continued)
2
2.
ADDITIONAL QUALIFYING CRITERIA: (Complete all that apply for your profession)
Licensed Psychologist:
a.
ABPP Diplomate In:
Counseling
Clinical
School
Year received _______________________________
b.
Doctorate in clinical or counseling or school psychology?
Yes
No
If "yes," was it from a program which was New York State registered or APA approved?
Yes
No
c.
Did you complete a formal internship which included psychotherapy training?
Yes
No
If yes, name of program: _________________________________________________ Date completed: ______ / ______ / ______
mo.
day
yr.
Was the internship accredited by the APA at that time?
Yes
No
d.
If your doctorate was in a field other than clinical or counseling or school psychology, did you take a formal respecialization
program in clinical or counseling or school psychology?
Yes
No
If yes, name of program: _________________________________________________ Date completed: ______ / ______ / ______
mo.
day
yr.
Physicians:
Have you completed a psychiatric residency?
Yes
No
If yes, name of program: _____________________________________________________ Date completed: ______ / ______ / ______
mo.
day
yr.
LCSW:
A qualified supervisor must have at least three years of full-time, post-MSW supervised experience in diagnosis and psychotherapy,
prior to supervising the applicant.
Please note that other direct practice with clients does not qualify under New York State Law. In order to determine if you are qualified
to supervise, we must have the following information to evaluate your post-degree supervised experience in diagnosis and
psychotherapy.
Dates of Post-MSW
Weekly Client
Hours of Individual
Hours of Group
Supervisor License
Supervisor Name
Experience
Contact Hours
Supervision/Month
Supervision/Month
and Jurisdiction
Have you earned the “R” Psychotherapy Privilege?
Yes
No
Date conferred: ______ / ______ / ______
mo.
day
yr.
All Supervisors:
Have you completed a prescribed postgraduate program in psychotherapy in an institute chartered by the New York State Board of
Regents or one in another jurisdiction, which might be considered equivalent as determined by the State Board?
Yes
No
If yes, name of Institute: _________________________________________________________________________________________
Date completed: _______ / _______ / _______
mo.
day
yr.
Attach a copy of license and Curriculum Vitae.
Licensed Master Social Worker Form 4Q, Page 2 of 3, Rev. 11/15
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