Form 1swpr - Application For Licensed Clinical Social Worker November 2015 (Page 2 of 2) in pdf

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. This form must be signed and dated in the presence of

a Notary Public.

_______________________________________________________________________________ ________ / ________ / ________

Applicant’s Signature

mo.

day

yr.

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

Plan for Experience

Before starting the experience for the “R” privilege, you must submit for review and approval by the State Board for Social Work, a Plan for

Supervised Experience (Form 6) that will meet the requirements of this paragraph. The plan for supervision shall specify:

individual or group consultation of no less than two hours per month; or

enrollment in a program authorized to provide psychotherapy offered by an institution of higher education or by a psychotherapy

institute chartered by the Board of Regents.

The individual or group supervision must be provided by a Licensed Clinical Social Worker with the “R” privilege, a licensed psychologist or

a licensed physician who has a qualification in psychiatry, in the determination of the State Board. The experience must be completed in an

authorized setting, as defined in the Education Law and Part 74.5 of the Commissioners’ Regulations. You can access more information

about qualified supervisors in the Appendix A.

A Plan for Post-LCSW Supervised Experience (Form 6) must be submitted by the supervisor for review and approval by the State Board.

Your Form 6 will not be reviewed unless you have already submitted an Application for Licensed Clinical Social Worker Psychotherapy “R”

Privilege (Form 1SWPR) and $100 fee.

Mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany, NY

12201. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.

Licensed Clinical Social Worker Psychotherapy “R” Privilege Form 1SWPR, Page 2 of 2, Rev. 11/15

Form 1swpr - Application For Licensed Clinical Social Worker November 2015 Page 2