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Section II: Supervisor's Verification of Experience (Continued)

Attestation of Supervisor or Licensed Colleague

NOTE: If you are a licensed colleague attesting to the supervision provided by a qualified supervisor who is not available, and the

experience has been completed, you must provide in section II, item 2 of this form:

•

the name and qualifications of the supervisor;

•

the client contact hours in psychotherapy provided during the supervised experience;

•

the dates of supervision provided to the applicant; and

•

the frequency and type of supervision sessions.

I hereby certify that to the best of my knowledge and belief the foregoing is a true statement of the professional experience of the individual

named in Section I of this form and that I have read Appendix A and that the experience meets the requirements for the psychotherapy

privilege issued by the New York State Education Department. This form must be signed and dated in the presence of a Notary Public.

Signature: _________________________________________________________________________ Date: _______ / _______ / _______

mo.

day

yr.

Print name: ________________________________________________________________________

Agency: ___________________________________________________________________________

Address: ___________________________________________________________________________

___________________________________________________________________________

Phone: ____________________________________ Fax: ____________________________________

E-mail: ____________________________________________________________________________

Licensed as: ________________________________________________________________________

Licensed in the State of: _______________________________________________________________

License number: ____________________________________

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

Form 4swpr - Certification Of Experience For Licensed Clinical Social Worker Psychotherapy "R" Privilege Page 3