Licensed Master Social Worker Form 4q - Approval Of Qualifications To Supervise Psychotherapy Page 3
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3Section II: To be Completed by the Supervisor (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 determine my eligibility as a supervisor of LMSWs seeking licensure as an LCSW 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,
Social Work Unit, 89 Washington Avenue, Albany, NY 12234-1000
Licensed Master Social Worker Form 4Q, Page 3 of 3, Rev. 11/15
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