Licensed Clinical Social Worker Form 6 - Plan For Supervised Experience
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1
2
3
4The University of the State of New York
Licensed Clinical
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Social Worker Form 6
Division of Professional Licensing Services
Plan for Supervised Experience
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.
2.
Send the entire form along with a copy of Appendix A to your supervisor 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
3.
Print Name as It Appears on Your Application for Licensure (Form 1)
5
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.
You must complete 2000 client contact hours of post-MSW supervised experience in diagnosis, psychotherapy and assessment-based
treatment plans over a period of at least 36 months and no more than 6 years. You must have been supervised by a licensed clinical
social worker, licensed psychologist or physician who meets the requirements of section 74.6 of the Commissioner’s Regulations in an
acceptable setting as defined in section 74.6.
Name of proposed clinical supervisor: ______________________________________________________________________________
Name of setting: _______________________________________________________________________________________________
Setting address: _______________________________________________________________________________________________
LMSW License Number:
Date LMSW License issued: Month
Day
Year
Date MSW degree awarded: _______ / _______ / _______
mo.
day
yr.
7
. Attestation
10
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 Form 6, page 1 of 3, Rev. 11/15
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