Licensed Clinical Social Worker Form 6 - Plan For Supervised Experience (Page 4 of 4) in pdf

The Form 6 should be submitted prior to starting the practice of clinical social work to meet the

experience requirements for licensure in New York or when your employment changes. You and your

prospective employer/supervisor should complete the form and submit it to the State Board for review of

the setting and the supervisor.

In order to meet the experience requirement for licensure, you must complete at least 2,000 client

contact hours in the practice of diagnosis, psychotherapy and assessment-based treatment planning

under a qualified supervisor, in a setting authorized to provide clinical social work services. The

supervisor must provide at least 100 in-person hours of individual and/or group supervision. The specific

requirements for supervised practice may be found in section 74.6 of the Commissioner's Regulations.

Your prospective supervisor/employer must indicate the type of setting (e.g., hospital, prison, or private

practice) where you will be employed. The supervisor must attach a copy of the operating certificate

issued by the appropriate government agency (e.g., Department of Health for Article 28 clinic) for the

agency, or in the case of a private practice, proprietorship or professional corporation a copy of the

certificate of incorporation, or a copy of the waiver issued by the Department to a qualified not-for-profit

or educational corporation under section 6503-a of the Education Law, when issued

The supervisor must indicate the profession in which he or she is licensed in New York and must be

registered to practice as an LCSW, licensed psychologist or psychiatrist. The supervisor should attach a

copy of his/her registration certificate with Form 6. You may not hire your supervisor; the supervisor must

be employed by the same agency that employs you and is responsible for supervision of your practice. If

this is the case, the agency must complete the appropriate section of Form 6.

The completed Form 6 should be signed and mailed to:

State Board for Social Work

Office of the Professions, State Education Building

89 Washington Avenue, Albany, NY 12234-1000

The form and attachments will be reviewed and you will receive an acknowledgement, if acceptable, or

we will contact you with any questions.

The approval of the Form 6 should not be taken as approval of your experience; the supervisor is

responsible for submitting verification of experience on Form 4B. When you have completed at least

2,000 client contact hours of supervised experience or you leave this setting, you and the supervisor

should submit Form 4B to the State Board. We will review experience after you have submitted the

application for licensure (Form 1) and fee and your clinical education has been approved by the

Department. When your clinical education and experience are approved, you will be eligible for the

licensing examination. You may only practice clinical social work under supervision until you are

licensed as an LCSW.

Licensed Clinical Social Worker Form 6 - Plan For Supervised Experience Page 4