Form 4swpr - Certification Of Experience For Licensed Clinical Social Worker Psychotherapy "R" Privilege

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The University of the State of New York
Licensed Clinical Social
Assigned No.
THE STATE EDUCATION DEPARTMENT
(From Form 1SWPR)
Worker Psychotherapy
Office of the Professions
Division of Professional Licensing Services
__________
“R” Privilege
Form 4SWPR
Certification of Experience for Licensed Clinical Social Worker
Psychotherapy “R” Privilege
Applicant Instructions
1.
Complete Section I. In item 3, enter your name exactly as it appears on your Application for Licensure (Form 1). Be sure to sign and date item 7. Use the
psychotherapy log to document your hours of practice and supervision. This log must be completed by you and your supervisor. All pages of the log must
be submitted along with this form.
2.
Send the entire form along with a copy of Appendix A to your supervisor (if your supervisor is unavailable, you must provide the supervisor’s
qualifications and your experience may be verified by a licensed colleague.) and ask him/her to complete Section II and forward 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 submitted by the applicant.
Section I: Applicant Information
1
2
1.
Social Security Number
2. Birth Date
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3.
Print Name as It Appears on Your Application for Licensure (Form 1SWPR)
5
3
6.
Telephone/E-Mail Address
Last
Daytime phone
First
Area Code
Phone
Middle
E-mail Address
(please print clearly)
4
4.
Mailing Address
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
6
6.
Complete this item to verify that you have completed the required supervision experience necessary for the psychotherapy privilege. You must complete
2,400 client contact hours and 36 months of experience, with no less than 400 client contact hours per year after the experience that qualified you for
licensure as an LCSW. You must have been supervised by a licensed clinical social worker, licensed psychologist or physician who meets the
requirements of section 74.5 of the Commissioner’s Regulations.
Name of clinical supervisor: ____________________________________________________________________________________________________
Title of supervisor: ___________________________________________________________________________________________________________
Name of Agency/Private Practice: _______________________________________________________________________________________________
Agency/Private Practice address: _______________________________________________________________________________________________
LCSW License Number:
Date LCSW License issued:
Month
Day
Year
From: _______ / _______ / _______ to: _______ / _______ / _______ please indicate a date no later than today’s
mo.
day
yr.
mo.
day
yr.
7
10. Attestation
I declare and affirm that the statements made in the foregoing application, including accompanying statements are true, complete and correct. I
understand that any false or misleading information in, or in connection with my application may be cause for denial of qualification and may lead to a
filing of charges of professional misconduct.
_________________________________________________________________________________________ ________ / ________ / ________
Applicant’s Signature
mo.
day
yr.
Licensed Clinical Social Worker Psychotherapy “R” Privilege Form 4SWPR, Page 1 of 3, Rev. 11/15

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