Certification And Licensure Board - Lcswa Six-Month Review Form (Page 2 of 2) in pdf

Certification And Licensure Board - Lcswa Six-Month Review Form Page 2

SECTION IV: (Required) Provide a narrative summary regarding the LCSWA licensee’s growth as a clinical practitioner and

participation in clinical supervision.

__________________________________________________________________________________________

Supervision period (mm/dd/yyyy): ______________ to ________________

Hours of Supervision provided (this review period only): GROUP_________INDIVIDUAL _________

Clinical Practice Hours (this review period only): __________

I affirm that the supervisee has practiced clinical social work and has demonstrated skill through practice experience as

defined by statute [NCGS 90B-3] and Code [21 NCAC 63 .0102]; and that the above hours of supervision have occurred with

the LCSWA as indicated. I certify that I am a current LCSW with a graduate degree in social work from a CSWE accredited

program and that I am in good standing with the Board.

Supervisor Signature_____________________________________Date signed _____/_____/_______

YYYY

Print name__________________________________ LCSW #: _____________Expires: ____/____/______

MM DD YYYY

Daytime phone # ________________

Please retain a copy of this document for your files. [In accordance with NCGS 90B-6(i), you are required to maintain

records for a minimum of 3 years from the date services are terminated.] You will not receive a response from the

Board unless there is a concern or additional action is needed. If you wish to confirm receipt, please mail to the Board

by traceable service.

BELOW SPACE FOR BOARD USE ONLY

Approval is granted for appropriately supervised clinical practice pursuant to NCGS 90B, the Social Worker

Certification and Licensure Act, and Title 21, Chapter 63 of the N.C. Administrative Code, defining clinical

social work practice, and at the required 1:30 supervision ratio.

Reviewer’s Initials: ________

Date of Review: _____/_____/_______ Follow Up Needed: ________

MM DD

YYYY

Yes / No

Certification And Licensure Board - Lcswa Six-Month Review Form Page 2