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Section II: Supervisor's Verification of Experience

Instructions For Completing Section II: Please complete Section II, be sure to sign the affidavit, have your signature notarized by a

Notary Public and return 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 returned by the applicant. By completing Section II and the psychotherapy log, the supervisor is certifying that the person named

in Section I received supervision that meets the requirements specified in Education Law and the Commissioner's Regulations.

Name of applicant: _____________________________________________________________________________________________

(Item 3 on page 1)

Name of supervisor: ____________________________________________________________________________________________

(Supervisor must complete Form 4Q if not already approved by Department)

Title: ________________________________________________________________________________________________________

(attach copy of supervisor’s license)

Setting where the applicant provided diagnosis and psychotherapy services under your supervision:

Name of facility: ___________________________________________________________________________________________________

Address: _________________________________________________________________________________________________________

The facility is a (check one and attach copy of authorization to provide services):

 Private practice owned by applicant. (LCSW)

 Private practice owned by the supervisor. (LCSW-R, Licensed Psychologist or Psychiatrist)

 Program approved by New York State Office of Mental Health (OMH), Office for People with Developmental Disabilities (OPWDD),

Office of Alcoholism & Substance Abuse Services (OASAS), Office of Children & Family Services (OCFS), Department of Correction

Services, State Office for the Aging , Department of Health, or local social service or mental hygiene district. (Attach copy of operating

certificate)

 Professional entity registered with the New York State State Education Department and authorized to provide psychotherapy and/or

clinical social work services. (Attach certificate of incorporation)

 Not-for-Profit or educational corporation authorized by a waiver issued by the State Education Department. (Attach copy of

authorization.)

 Enrollment in a psychotherapy program in an institution of higher education, psychotherapy institute chartered by Board of Regents and

authorized to provide psychotherapy to the public (attach copy of Regents Charter)

 Elementary, middle, high school or college authorized to provide psychotherapy services to students. (Attach copy of Regents Charter)

 Other entity authorized under law to employ licensed professionals and provide services. (Attach copy of certificate of incorporation)

You must initial each section to verify the applicant was appropriately supervised:

_____________ Education Law and Commissioner’s Regulations define acceptable experience as at least 400 client contact hours per

year in diagnosis and psychotherapy. Failure to provide appropriate supervision could result in charges of unprofessional

conduct against the licensed supervisor.

_____________ Acceptable supervision is defined as the applicant apprising the supervisor of the diagnosis and treatment of each client,

cases are discussed, the supervisor provides oversight and guidance to the applicant in diagnosis and treatment, the

supervisor reviews and evaluates the applicant’s work and provides the minimum hours of supervision each month, that is:

•

Two hours/month of individual, group consultation; or

•

Enrollment in a program of psychology offered by an institutions of higher education or psychotherapy institute

chartered by the Board of Regents (Name: __________________________________________________________ )

_____________ A record of client contact hours and supervision has been completed and retained by the supervisor.

Indicate the number of client contact hours of psychotherapy provided over the period below: _____________________________________

Applicant was supervised from: _______ / _______ / _______ to _______ / _______ / _______ (no later than today’s date)

mo.

day

yr.

mo.

day

yr.

Licensed Clinical Social Worker Psychotherapy “R” Privilege Form 4SWPR, Page 2 of 3, Rev. 11/15

Form 4swpr - Certification Of Experience For Licensed Clinical Social Worker Psychotherapy "R" Privilege Page 2

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