Certification And Licensure Board - Lcswa Six-Month Review Form

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NORTH CAROLINA SOCIAL WORK
CERTIFICATION AND LICENSURE BOARD
P.O. Box 1043
Email:
Asheboro, NC 27204
Website:
Ph: 336-625-1679 / 800-550-7009
LCSWA SIX-MONTH REVIEW
Review Period: __/__/____ to: __/__/___
mm/dd/yyyy
mm/dd/yyyy
All LCSWA licensees are required to receive supervision of their clinical social work practice during their associate
status. Appropriate supervision, unless otherwise pre-approved by the Board (in writing), shall be provided by a North
Carolina licensed LCSW in good standing with the Board, who has a MSW degree, and at least two years of post LCSW
clinical practice experience. Supervision and practice shall be reported to the Board every six months pursuant to NC
Administrative Code [21 NCAC 63 .0210].
SECTION I: To be completed by the LCSWA licensee
Name (Print): _______________________________________
LCSWA # _________________
Place of Employment (for this review period): _________________________________________
Is attached □
Has already been submitted □
Employment Verification (check one):
OR
LCSWA Daytime Phone: _______________
LCSWA Signature: _____________________________________
Date: _______________
mm/dd/yyyy
SECTION II: LCSW clinical supervisor shall acknowledge by checkmark (√) or initials that each bulleted item has been
completed.
_____ Position Statement has been signed and submitted to the Board.
_____ Emergency Crisis Plan has been submitted to the Board insuring immediate access to emergency
consultation.
_____ A supervisory log has been maintained and is available upon request to verify documented supervision.
_____ Case narrative summarizing one case treated during this review period has been prepared, reviewed, and
is on file and available for Board review if needed.
SECTION III: To be completed by LCSW clinical supervisor. You are encouraged to share your assessment with your
supervisee as part of the supervision process.
Rate the LCSWA supervisee in all areas using the following key: (Reference the Supervisor Manual for an explanation of
key terms). Excellent (E) Very Good (VG)
Good (G)
Fair (F)
Poor (P)
1._____Ethical standards of social work practice
8. _____Ability to implement interventions
2._____Effective use of supervision
consistent with the treatment plan
3._____Competence in social work practice
9. _____Supervisee’s ability to assess
4._____Professional growth and development
his/her own capacities and skills
5._____Consistency of performance effort
10. _____Ability to correctly diagnose
6._____Knowledge of social work principles and practices
mental and emotional disorders
7._____Ability to formulate a treatment plan appropriate
11. _____Ability to plan treatment & carry out
to the clients’ needs
clinical interventions related to mental
& emotional disorders

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