Form 4b - Certification Of Experience For Licensed Clinical Social Worker
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4The University of the State of New York
Licensed Clinical
Assigned No.
THE STATE EDUCATION DEPARTMENT
(From Form 4)
Office of the Professions
Social Worker Form 4B
Division of Professional Licensing Services
__________
Certification of Experience for Licensed Clinical Social Worker
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. This log must be completed by you and
your supervisor. All pages of the log must be retained by the supervisor, in the event the State Board requests clarification.
2.
Send the entire form along with a copy of Appendix A to your supervisor (if your supervisor is unavailable, you must provide the
supervisor’s qualifications and your experience may be verified by a licensed colleague) 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
5
6.
Telephone/E-Mail Address
3.
Print Name as It Appears on Your Application for Licensure (Form 1)
Daytime phone
Last
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.
Complete this item to verify that you have completed the required supervised experience necessary for licensure as an LCSW. You
must complete 3 years of full-time post-MSW supervised experience and 2000 client contact hours in diagnosis, psychotherapy and
assessment-based treatment plans over a period not to exceed six 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.
Name of clinical supervisor: _____________________________________________________ Assigned number from Form 4 _______
Name of setting: _______________________________________________________________________________________________
Setting address: _______________________________________________________________________________________________
LMSW License Number:
Date LMSW License issued: Month
Day
Year
7
. Attestation
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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 4B, Page 1 of 3, Rev. 11/15
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