Form 4b - Certification Of Experience For Licensed Clinical Social Worker (Page 2 of 4) in pdf

Section II: Supervisor's Verification of Experience

Instructions For Completing Section II: Please complete Section II, be sure to sign the affidavit, have your signature notarized by a

Notary Public and return 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 returned by the applicant. By completing Section II, the supervisor is certifying that the person named in Section I received

supervision that meets the requirements specified in Education Law and the Commissioner's Regulations.

Name of applicant: _____________________________________________________________________________________________

(Item 3 on page 1)

Name of supervisor: ____________________________________________________________________________________________

(Supervisor must complete Form 4Q if not already approved by Department)

Title: ________________________________________________________________________________________________________

(attach copy of supervisor’s license)

Setting where the applicant provided diagnosis and psychotherapy services under your supervision:

Name of facility or private practice: ____________________________________________________________________________________

Address: _________________________________________________________________________________________________________

The facility is a (check one and attach copy of authorization to provide services):

 Private practice owned by supervisor (LCSW, Licensed psychologist or psychiatrist)

 Sole proprietorship owned by supervisor

 Professional entity (PLLC, PLLP, P.C.) owned by supervisor

 Professional Partnership

 Program approved by the New York State Office of Mental Health (OMH), Office for People with Developmental Disabilities (OPWDD),

Office of Alcoholism & Substance Abuse Services (OASAS), Office of Children & Family Services (OCFS), Department of Corrections,

State Office for the Aging, Department of Health, or local social service or mental hygiene district (attach operating certificate)

 Psychotherapy institute chartered by Board of Regents and authorized to provide psychotherapy to the public (attach copy of Regents

Charter)

 Elementary, middle, high school or college or educational corporation authorized to provide psychotherapy services to students (attach

copy of authorization)

 Not-for-profit or other entity authorized by certificate of incorporation or waiver from SED to employ licensed professionals and provide

services (attach certificate of incorporation)

Supervisor must initial each section to verify appropriate supervision of the applicant:

_____________ Education Law and Commissioner’s Regulations define acceptable experience as 2000 client contact hours in diagnosis,

psychotherapy and assessment-based treatment planning. The supervisor is responsible for the assessment, evaluation

and treatment of patients seen by the applicant and for delegating to the applicant those activities he/she is competent to

perform. Failure to provide appropriate supervision could result in charges of unprofessional conduct against the licensed

supervisor.

_____________ Acceptable supervision is defined as the applicant apprising the supervisor of the diagnosis and treatment of each client,

cases are discussed, the supervisor provides oversight and guidance to the applicant in diagnosis and treatment, the

supervisor reviews and evaluates the applicant’s work and provides at least 100 hours in person supervision.

_____________ A record of client contact hours and supervision hours has been completed and retained by the supervisor for the following

period:

starting: _______ / _______ / _______

ending: _______ / _______ / _______

mo.

day

yr.

mo.

day

yr.

Total number of client contact hours of psychotherapy provided during the period you supervised the applicant: ____________________

Total number of supervision hours you provided: ____________________

Licensed Clinical Social Worker Form 4B, Page 2 of 3, Rev. 11/15

Form 4b - Certification Of Experience For Licensed Clinical Social Worker Page 2

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