The Clinical Social Experience Verification form is a crucial document used in California for aspiring clinical social workers. This form, which must be completed by a supervisor, verifies the applicant's supervised experience in clinical social work, mental health counseling, or psychotherapy. It is essential to ensure that all information is accurate and complete before submission, as it plays a significant role in the licensure application process.
To begin your journey towards licensure, please fill out the form by clicking the button below.
The Clinical Social Experience Verification form is a crucial document for aspiring clinical social workers in California, serving as a key component in the licensure application process. This form ensures that applicants have received adequate supervision and have met the necessary experience requirements while working in a clinical setting. It requires the applicant’s supervisor to provide detailed information about the work environment, confirming that it lawfully offered clinical social work, mental health counseling, or psychotherapy. Additionally, the supervisor must affirm that they provided oversight to ensure the applicant's work adhered to the experience and supervision standards set forth by the Board of Behavioral Sciences. The form also outlines specific experience metrics, including total supervised weeks, hours of supervision, and the nature of clinical work performed. Accuracy is paramount; any discrepancies or false information can lead to serious consequences, including denial of the application. Therefore, it is essential for both the applicant and supervisor to complete the form meticulously, ensuring all sections are filled out correctly and signed appropriately before submission.
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?
SUPERVISOR INFORMATION
Supervisor’s Name
Email Address (OPTIONAL)
License Type
License Number
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?
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)
1 of 2
APPLICANT NAME: __________________________________________ ASW#: _______________
SUPERVISOR INFORMATION (continued)
Were you (the supervisor) employed by the supervisee’s employer?
If NO, did you and the supervisee’s employer sign a written agreement pertaining to oversight of
the supervisee?
EXPERIENCE INFORMATION:
Dates of experience: From ____________
to ____________
(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
additional hours of face-to-face group supervision provided for every week in which more
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
2 of 2
After completing the Clinical Social Experience Verification form, the next steps involve submitting it along with your Application for Licensure. Ensure that all information is accurate and that the form has been properly signed by the supervisor. This form is essential for verifying your clinical social work experience.
What is the purpose of the Clinical Social Experience Verification form?
The Clinical Social Experience Verification form is designed to confirm the clinical social work experience of an Associate Social Worker (ASW) under the supervision of a qualified professional. This form must be completed by the supervisor and submitted with the application for licensure. It ensures that the ASW has met the necessary experience and supervision requirements mandated by the Board of Behavioral Sciences in California.
Who needs to complete this form?
This form must be completed by the ASW's supervisor. Each supervisor must fill out a separate form for every employer. The supervisor is responsible for verifying the ASW's clinical experience, ensuring that it aligns with the standards set by the Board. It is crucial that the supervisor provides accurate information and signs the form, as any discrepancies may affect the licensure application.
What information is required from the supervisor on this form?
The supervisor must provide their name, contact information, license type, and license number. They need to confirm their employment status in relation to the ASW and detail the dates of the ASW's experience. Additionally, the supervisor must report the total supervised weeks, hours of individual and group supervision, and the total hours of clinical work performed by the ASW. This information is essential to demonstrate that the ASW has met the required experience criteria.
What happens if the form is incomplete or contains false information?
It is vital that the Clinical Social Experience Verification form is complete and accurate. Providing false information or omitting important details may lead to the denial of the application for licensure. The Board of Behavioral Sciences takes such matters seriously and may impose disciplinary actions on any licensee involved in fraudulent activities. Therefore, both the ASW and the supervisor should ensure that all information is truthful and fully documented before submission.
Filling out the Clinical Social Experience Verification form is a crucial step in the licensure process for clinical social workers. However, many applicants make mistakes that can delay or even jeopardize their application. Understanding these common errors can help ensure a smoother submission.
One frequent mistake is failing to use a separate form for each supervisor and employer. This requirement is essential for accurately documenting diverse experiences. When multiple supervisors are involved, it is vital to provide clear and distinct information for each one. Neglecting this can lead to confusion and may result in the application being returned for corrections.
Another common error is submitting an incomplete or incorrect form. Applicants must ensure that all sections are filled out accurately before signing. Omissions or inaccuracies can lead to significant delays. It is advisable to double-check all information, including dates and hours worked, to avoid these issues.
Providing a signature that does not meet the requirements is also a mistake many make. The form requires an original or electronic signature, and any changes must be initialed by the signer. Failing to follow these instructions can raise questions about the authenticity of the document and lead to complications in the review process.
Some applicants overlook the necessity of detailing their employer's information correctly. This includes the employer's name, address, and phone number. Missing or incorrect details can create barriers in verifying the applicant's experience, which is crucial for the licensing board.
Additionally, individuals often miscalculate their total hours of experience. It is important to accurately track and report the number of hours spent in various categories, such as individual supervision and group supervision. Misrepresenting these figures can lead to disqualification from the licensing process.
Another oversight involves the supervisor's qualifications. Applicants must ensure that the supervisor's license type and number are correctly noted. If the supervisor is a physician, it is necessary to confirm that they have been certified in Psychiatry throughout the supervision period. Missing this information can complicate the verification process.
Lastly, applicants sometimes fail to provide the necessary additional documentation. If a supervisor has been licensed for less than two years, the applicant must attach out-of-state license information. Not including this can result in delays or outright denial of the application.
Being aware of these common mistakes can greatly enhance the chances of a successful application. Taking the time to review and ensure accuracy can make all the difference in the timely processing of the Clinical Social Experience Verification form.
The Clinical Social Experience Verification form is a crucial document for applicants seeking licensure as clinical social workers in California. Several other forms and documents are often required in conjunction with this verification form to ensure a comprehensive application process. Below is a list of these related documents, each serving a specific purpose in the licensure application.
Each of these documents plays a vital role in the overall assessment of an applicant’s qualifications for licensure as a clinical social worker. Ensuring that all forms are accurately completed and submitted can significantly impact the outcome of the application process.
When filling out the Clinical Social Experience Verification form, attention to detail is crucial. Here are nine essential do's and don'ts to guide you through the process:
Adhering to these guidelines will help ensure that your application process is smooth and successful.
Misconceptions about the Clinical Social Experience Verification form can lead to confusion and potential setbacks in the licensure process. Here are eight common misunderstandings, along with clarifications to help applicants navigate this important requirement.
This is incorrect. Each supervisor must complete a separate form. This ensures that all experiences and qualifications are accurately represented.
Applicants should ensure the form is complete and correct before signing. An incomplete form may lead to delays or denial of the application.
In fact, both original and electronic signatures are acceptable. However, any changes made must be initialed by the signer.
It is essential that the supervisor holds the appropriate license. The form requires detailed supervisor information, including license type and number.
Applicants must meet specific hour requirements, including a minimum of 104 supervised weeks and 2,000 hours of clinical experience.
The Clinical Social Experience Verification form must accompany the Application for Licensure. Failing to submit it together may result in application rejection.
Only hours that meet the defined criteria for individual, triadic, or group supervision are counted. Applicants should ensure their experience aligns with these definitions.
This is a serious misconception. Knowingly providing false information can lead to denial of the application and potential disciplinary actions against a licensee.
Understanding these misconceptions can help applicants prepare their Clinical Social Experience Verification form accurately and efficiently, ultimately aiding in the licensure process.
When completing the Clinical Social Experience Verification form, it is essential to follow specific guidelines to ensure accuracy and compliance. Here are some key takeaways to keep in mind:
By adhering to these guidelines, you can help facilitate a smoother application process and demonstrate your commitment to meeting the necessary requirements for licensure.