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Fill Out a Valid Clinical Social Experience Verification Form

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The Clinical Social Experience Verification form is a crucial document for aspiring clinical social workers in California, serving as a key component of the licensure application process. This form requires detailed information from both the applicant and their supervisor to ensure that the experience gained meets the state's regulatory standards. Each supervisor must complete a separate form, emphasizing the importance of accurate and thorough documentation. The applicant's employer information, along with the supervisor's qualifications, is essential in establishing the legitimacy of the clinical setting. Critical questions assess whether the setting provided appropriate oversight and whether the applicant's work fell within the scope of practice. Additionally, the form collects specific data regarding the applicant's supervised experience, including total hours of individual and group supervision, clinical work, and client advocacy. This verification process is designed to protect the integrity of the profession, ensuring that all applicants have met the necessary requirements before obtaining their license. It is imperative that all information provided is complete and truthful, as any discrepancies could lead to serious consequences, including the denial of licensure. Therefore, understanding the significance and requirements of this form is vital for a successful application.

Common mistakes

  1. Incomplete Information: Failing to fill out all required fields can lead to delays or rejection. Ensure that every section is completed, including the applicant's name, ASW number, and employer details.

  2. Incorrect Dates: Providing inaccurate dates for experience can result in issues. Double-check the start and end dates to confirm they reflect the actual experience period.

  3. Signature Issues: Not obtaining the correct signature can cause complications. Make sure the supervisor signs the form and initials any changes. An original or electronic signature is required.

  4. Omitting Required Attachments: Failing to attach necessary documentation, such as out-of-state license information if applicable, may hinder the application process. Review the requirements carefully.

  5. Misunderstanding Supervision Requirements: Not adhering to the supervision guidelines can lead to insufficient hours being reported. Ensure that the hours of supervision meet the minimum requirements outlined in the form.

Preview - Clinical Social Experience Verification Form

STATE OF CALIFORNIA - BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY

Gavin Newsom, Governor

Board of Behavioral Sciences

1625 North Market Blvd., Suite S200, Sacramento, CA 95834

Telephone: (916) 574-7830

www.bbs.ca.gov

CLINICAL SOCIAL WORKER

IN-STATE EXPERIENCE VERIFICATION

Have your supervisor complete this form as described below:

oUse a separate form for each supervisor and employer

oMake sure this form is complete and correct prior to signing

oProvide an original or electronic signature and have the signer initial any changes

oSubmit with your Application for Licensure

APPLICANT NAME: ___________________________________

 

ASW Number: ___________

 

 

APPLICANT’S EMPLOYER INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Applicant’s Employer:

 

 

 

 

 

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

Number and Street

 

 

 

City

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

1. Did this setting lawfully and regularly provide clinical social work, mental health counseling or

 

psychotherapy?

Yes

No

 

 

 

 

 

 

 

 

 

 

2. Did this setting provide oversight to ensure the ASW’s work met the experience and supervision

 

requirements and was within the scope of practice?

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPERVISOR INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supervisor’s Name

 

 

 

Telephone

 

 

 

 

Email Address (OPTIONAL)

 

 

 

 

 

 

 

 

 

 

 

 

 

License Type

 

 

License Number

 

 

State

 

 

Date First Licensed*

 

 

 

 

 

 

If a physician, were you certified in Psychiatry by the American Board of Psychiatry and Neurology during

 

the entire period of supervision?

 

Yes

No

N/A

 

 

 

 

 

 

 

 

If YES, provide certificate number:_________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*If licensed in California for less than two years on the first date of experience claimed, attach out-of-state license information

37A-201 (Revised 01/2022)

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APPLICANT NAME: __________________________________________ ASW#: _______________

SUPERVISOR INFORMATION (continued)

 

Were you (the supervisor) employed by the supervisee’s employer?

Yes

No

 

 

 

 

 

If NO, did you and the supervisee’s employer sign a written agreement pertaining to oversight of

 

 

the supervisee?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

EXPERIENCE INFORMATION:

Dates of experience: From ____________

to ____________

 

 

 

 

(mm/dd/yyyy)

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

1.

Total supervised weeks (Minimum 104 overall):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Total hours in individual or triadic supervision (Minimum 52 overall):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Total hours in group supervision:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Average hours worked per week (Maximum 40):

 

 

 

 

 

 

 

 

 

 

 

5. Total hours of clinical psychosocial diagnosis, assessment, and treatment, including

A.

 

 

 

 

individual or group psychotherapy / counseling (Minimum 2,000 overall):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Of the above hours, how many were gained performing face-to-face individual or

 

 

 

 

 

group psychotherapy/counseling

(Minimum 750 overall):

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Total hours of client-centered advocacy, consultation, evaluation, research,

 

B.

 

 

 

 

workshops, seminars, training sessions or conferences and direct supervisor contact*

 

 

 

 

 

(Maximum 1,000 overall):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Total hours of experience (Minimum 3,000 overall):

(A + B = C)

C.

 

 

 

 

 

 

 

 

 

 

9.

Was one additional hour of face-to-face individual or triadic supervision OR two

 

 

Yes

 

 

additional hours of face-to-face group supervision provided for every week in which more

 

No

 

 

than 10 hours of direct clinical counseling was performed?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*A maximum of six (6) hours of direct supervisor contact per week may be counted toward the 1,000 hours.

NOTE: Knowingly providing false information or omitting pertinent information may be grounds for denial of the application. The Board may take disciplinary action on a licensee who helps an applicant obtain a license by fraud, deceit or misrepresentation. All information on this form is subject to verification.

Signature of Supervisor: _____________________________________ Date: ______________

ORIGINAL OR ELECTRONIC SIGNATURE REQUIRED

37A-201 (Revised 01/2022)

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Documents used along the form

When applying for licensure as a clinical social worker in California, several key documents are typically required alongside the Clinical Social Experience Verification form. Each of these forms plays a crucial role in verifying your qualifications and ensuring that you meet the necessary standards for licensure. Below is a list of commonly used documents that you may encounter in this process.

  • Application for Licensure: This is the primary document that initiates your request for licensure. It collects essential personal information, educational background, and work history. Completing this application accurately is vital, as it serves as the foundation for your licensure review.
  • Verification of Supervised Experience: This document details the specific hours and types of clinical experience you have accumulated under supervision. It outlines your work settings, the nature of your duties, and the qualifications of your supervisors. This verification is critical in demonstrating that you have met the required experience standards.
  • Transcripts from Educational Institutions: Official transcripts from your degree-granting institution are needed to confirm that you have completed the necessary educational requirements for licensure. These transcripts provide evidence of your academic qualifications and the courses you have completed relevant to social work.
  • RV Bill of Sale Form: Essential for the transfer of ownership of a recreational vehicle, this form serves as legal documentation of the transaction, confirming the change of ownership. For Texas, you can find the necessary template here: https://autobillofsaleform.com/rv-bill-of-sale-form/texas-rv-bill-of-sale-form/.
  • Background Check Authorization: Most licensing boards require a background check to ensure that applicants have no disqualifying criminal history. This document authorizes the board to conduct a thorough review of your criminal record and other relevant background information.

Gathering these documents can seem daunting, but each one is essential for a smooth licensure process. Ensure that all forms are completed accurately and submitted on time to avoid any delays in your application. Being well-prepared will help you move forward confidently in your career as a clinical social worker.

Similar forms

The Clinical Social Experience Verification form shares similarities with the Internship Verification form used in various professional fields. Both documents serve to confirm that an individual has completed a certain amount of supervised experience in a specific setting. In the case of the Internship Verification form, it requires the intern's supervisor to attest to the intern's competencies and the nature of the work performed. Like the Clinical Social Experience Verification form, it includes sections for supervisor details and the verification of hours worked, ensuring that the experience meets the necessary standards for licensure or certification.

Another document that resembles the Clinical Social Experience Verification form is the Practicum Experience Verification form. This form is often utilized by students in graduate programs, particularly in psychology and counseling. It requires the completion of specific sections by the student's supervisor, detailing the hours of direct client contact and supervision received. Both forms emphasize the importance of documented experience and supervisor oversight, ensuring that the individual has gained the necessary skills to practice competently in their field.

The Supervised Experience Verification form is also similar, particularly in the context of nursing and healthcare professions. This form is designed to validate the clinical hours and experiences of nursing students or graduates seeking licensure. Just like the Clinical Social Experience Verification form, it requires a supervisor's signature and details about the supervised hours worked. Both documents aim to ensure that the applicant has received adequate training and oversight during their practical experience.

To ensure clarity and professionalism during the sale of a mobile home, it is essential to utilize the proper documentation, such as the Mobile Home Bill of Sale, which outlines the necessary details of the transaction. This document not only facilitates a smooth transfer of ownership but also protects the rights of both buyers and sellers throughout the process.

Additionally, the Verification of Clinical Hours form used in occupational therapy is comparable. This document is intended to verify the completion of required clinical hours as part of the certification process. It includes sections for supervisor information, the total number of hours worked, and the types of activities performed. Similar to the Clinical Social Experience Verification form, it ensures that the applicant has met the educational and practical requirements necessary for professional practice.

Finally, the Counseling Experience Verification form is another document that mirrors the Clinical Social Experience Verification form. This form is specifically tailored for individuals pursuing licensure in counseling. It requires detailed information about the applicant's supervised counseling experience, including hours worked and types of counseling provided. Both forms highlight the significance of supervision and documented experience, which are critical components in the licensure process for mental health professionals.

Dos and Don'ts

When filling out the Clinical Social Experience Verification form, it is essential to follow certain guidelines to ensure accuracy and compliance. Below is a list of things you should and shouldn't do:

  • Do use a separate form for each supervisor and employer.
  • Do ensure that the form is complete and correct before signing.
  • Do provide an original or electronic signature.
  • Do have the signer initial any changes made to the form.
  • Do submit the form with your Application for Licensure.
  • Don't forget to include the ASW number on the form.
  • Don't leave any required fields blank; ensure all information is filled in.
  • Don't provide false information or omit pertinent details.
  • Don't forget to check if the supervisor was employed by the supervisee's employer.

Key takeaways

  • Each supervisor must complete a separate Clinical Social Experience Verification form for every applicant. This ensures clarity and accuracy in documenting the experience.

  • Before signing, confirm that the form is fully completed and correct. Inaccuracies can lead to delays or complications in the licensure process.

  • Obtain an original or electronic signature from the supervisor. If any changes are made, the supervisor must initial them to maintain the integrity of the document.

  • Submit the completed form along with your Application for Licensure. This is a critical step in the application process.

  • Ensure that the work setting lawfully provided clinical social work or psychotherapy. This is a key requirement that must be affirmed on the form.

  • Document all hours accurately. The total hours of experience must meet the minimum requirements, including supervised weeks and clinical hours.

  • Be aware that providing false information or omitting important details can lead to application denial. The Board may also take disciplinary action against those who assist in fraudulent applications.

How to Use Clinical Social Experience Verification

Completing the Clinical Social Experience Verification form is an essential step in the application process for licensure. This form must be filled out accurately to reflect your clinical social work experience under the supervision of a qualified professional. Each supervisor must complete a separate form, ensuring that all required information is provided before submission.

  1. Begin by entering your name and ASW number at the top of the form.
  2. Provide your employer's information, including the name, telephone number, and address (number and street, city, state, zip code).
  3. Answer the first two questions regarding the setting's provision of clinical social work and oversight of your work. Mark "Yes" or "No" as applicable.
  4. Fill in your supervisor's information, including their name, telephone number, and optional email address. Include their license type and number, and the state in which they are licensed.
  5. Indicate the date your supervisor was first licensed and whether they were certified in Psychiatry during the entire supervision period. If they were, provide the certificate number.
  6. State whether the supervisor was employed by your employer. If not, indicate if a written agreement was signed regarding oversight.
  7. In the experience information section, list the dates of your experience, entering the start and end dates in the specified format (mm/dd/yyyy).
  8. Complete the required fields for total supervised weeks, total hours in individual or triadic supervision, total hours in group supervision, and average hours worked per week.
  9. Fill in the total hours of clinical psychosocial diagnosis, assessment, and treatment, including individual or group psychotherapy/counseling.
  10. Specify how many of those hours were spent on face-to-face individual or group psychotherapy/counseling.
  11. Document total hours for client-centered advocacy, consultation, evaluation, and other related activities.
  12. Calculate and enter the total hours of experience, ensuring it meets the minimum requirement.
  13. Answer the final question regarding supervision provided for weeks with more than 10 hours of direct clinical counseling.
  14. Have your supervisor sign and date the form, ensuring that the signature is original or electronic.

After completing the form, ensure that all information is accurate and clear. Submit this form along with your application for licensure to the appropriate board for processing.