Article Structure
The Clinical Social Experience Verification form is an essential document for individuals seeking licensure as clinical social workers in California. This form must be completed by a qualified supervisor and serves multiple purposes during the application process. It captures critical details such as the applicant's employment information, the nature of the supervisor's licensure, and specific criteria regarding the clinical work performed. Applicants are required to use a separate form for each supervisor and employer, ensuring accurate and comprehensive reporting of their experience. The supervisor must certify that the employer provided lawful clinical social work services and maintained oversight of the applicant's professional development. Key metrics include the total supervised weeks, hours of supervision, and the extent of clinical work completed, which includes individual and group therapy. Importantly, the form emphasizes the requirement for specific totals, such as a minimum of 3,000 hours of clinical experience, including face-to-face interaction with clients. Precise completion is crucial, as any inaccuracies or omissions can lead to denial of the application. This form embodies a transparent process aimed at maintaining high standards within the social work profession in California.
Clinical Social Experience Verification Example
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)
www.bbs.ca.gov
CLINICAL SOCIAL WORKER
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: ___________________________________ |
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ASW Number: ___________ |
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APPLICANT’S EMPLOYER INFORMATION |
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Name of Applicant’s Employer: |
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Telephone |
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Address: |
Number and Street |
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City |
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State |
Zip Code |
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1. Did this setting lawfully and regularly provide clinical social work, mental health counseling or |
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psychotherapy? |
Yes |
No |
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2. Did this setting provide oversight to ensure the ASW’s work met the experience and supervision |
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requirements and was within the scope of practice? |
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Yes |
No |
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SUPERVISOR INFORMATION |
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Supervisor’s Name |
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Telephone |
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Email Address (OPTIONAL) |
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License Type |
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License Number |
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State |
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Date First Licensed* |
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If a physician, were you certified in Psychiatry by the American Board of Psychiatry and Neurology during |
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the entire period of supervision? |
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Yes |
No |
N/A |
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If YES, provide certificate number:_________________ |
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*If licensed in California for less than two years on the first date of experience claimed, attach
1 of 2 |
APPLICANT NAME: __________________________________________ ASW#: _______________
SUPERVISOR INFORMATION (continued)
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Were you (the supervisor) employed by the supervisee’s employer? |
Yes |
No |
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If NO, did you and the supervisee’s employer sign a written agreement pertaining to oversight of |
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the supervisee? |
Yes |
No |
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EXPERIENCE INFORMATION: |
Dates of experience: From ____________ |
to ____________ |
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(mm/dd/yyyy) |
(mm/dd/yyyy) |
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1. |
Total supervised weeks (Minimum 104 overall): |
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2. |
Total hours in individual or triadic supervision (Minimum 52 overall): |
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3. |
Total hours in group supervision: |
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4. |
Average hours worked per week (Maximum 40): |
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5. Total hours of clinical psychosocial diagnosis, assessment, and treatment, including |
A. |
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individual or group psychotherapy / counseling (Minimum 2,000 overall): |
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6. |
Of the above hours, how many were gained performing |
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group psychotherapy/counseling |
(Minimum 750 overall): |
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7. |
Total hours of |
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B. |
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workshops, seminars, training sessions or conferences and direct supervisor contact* |
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(Maximum 1,000 overall): |
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8. |
Total hours of experience (Minimum 3,000 overall): |
(A + B = C) |
C. |
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9. |
Was one additional hour of |
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Yes |
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additional hours of |
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No |
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than 10 hours of direct clinical counseling was performed? |
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*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: ______________ |
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ORIGINAL OR ELECTRONIC SIGNATURE REQUIRED |
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2 of 2 |
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Form Characteristics
| Fact | Description |
|---|---|
| Governing Body | The Clinical Social Experience Verification form is overseen by the Board of Behavioral Sciences in California. |
| Application Requirement | This form must be submitted along with the Application for Licensure for clinical social workers. |
| Supervision Criteria | It is required to have a supervisor complete this form, ensuring the supervision meets specific experience and practice standards. |
| Experience Hours | A minimum of 3,000 hours of clinical psychosocial diagnosis, assessment, and treatment is needed for licensure. |
| Supervision Structure | At least 104 weeks of supervised experience and 52 hours of individual or triadic supervision must be documented. |
| Face-to-Face Requirements | Applicants must have completed at least 750 hours of face-to-face individual or group psychotherapy or counseling. |
| Consequences of Misrepresentation | Providing false information on the form may lead to denial of the application and potential disciplinary action. |
Guidelines on Utilizing Clinical Social Experience Verification
Completing the Clinical Social Experience Verification form is an essential step in your application for licensure. It’s important to ensure that every detail is accurate and complete, as this will facilitate the review process. Each supervisor must fill out a separate form, and it should be accompanied by an original or electronic signature.
- Start by entering the applicant's name and their ASW number at the top of the form.
- Next, provide the employer information including the name of the applicant’s employer, their telephone number, and the complete address (street address, city, state, and zip code).
- Indicate if the setting lawfully provided clinical social work, mental health counseling, or psychotherapy by selecting Yes or No.
- Answer whether the setting provided oversight to ensure the ASW’s work met experience and supervision requirements.
- Fill in the supervisor information section, including the supervisor's name, telephone number, and optional email address.
- Record the type of license the supervisor holds, the license number, and the state in which they are licensed.
- Indicate the date first licensed. If the supervisor is a physician, state whether they were certified in Psychiatry during the entire supervision period.
- Complete the section asking if the supervisor was employed by the supervisee's employer and, if No, confirm whether a written agreement existed for oversight.
- Provide the experience information, filling out the dates of experience from start to end. Include total supervised weeks and various supervision hours as required.
- For each of the experience metrics, such as clinical diagnosis hours and face-to-face counseling hours, fill in the accurate numbers ensuring they meet minimum requirement thresholds.
- Respond to whether the required additional supervision was provided for weeks with substantial direct clinical counseling hours.
- Once all sections are filled, the supervisor must sign the form and enter the date of signing beneath the signature line.
What You Should Know About This Form
What is the purpose of the Clinical Social Experience Verification form?
This form is required for individuals applying for licensure as clinical social workers in California. It documents the supervised clinical experience and ensures that the applicant has met the necessary requirements for licensure. This verification from supervisors is crucial for confirming that the experience aligns with state regulations.
Who should complete the form?
The form must be filled out by a supervisor who has directly overseen the applicant's clinical social work experience. Each supervisor will need to complete a separate form for every employer to ensure accurate and verified data.
What information is required about the applicant's employment?
Applicants must provide the name of their employer, contact telephone number, and address details, including street, city, state, and zip code. This information is necessary to verify the legitimacy of the employment setting.
How many hours of supervision are required?
Applicants need to have a minimum of 104 weeks of supervised experience, with at least 52 hours of individual or triadic supervision. Additionally, documented experience in group supervision is also required, though there is no specific minimum stated.
What clinical experience must the applicant have logged?
The applicant must have at least 3,000 hours of total experience, which includes a minimum of 2,000 hours in clinical psychosocial diagnosis, assessment, and treatment, with at least 750 of those hours in face-to-face individual or group psychotherapy. This ensures that the applicant has substantial clinical exposure to various practices.
Can the supervisor be from a different employer?
If the supervisor is not employed by the same organization as the applicant, a written agreement regarding the oversight of the supervisee must be signed by both the supervisor and the employer's representative. This is important for confirming that proper oversight and accountability are maintained during the supervision process.
What happens if false information is submitted on this form?
Submitting false information, or omitting important details, may lead to denial of the application for licensure. The Board has the authority to take disciplinary action against a licensee involved in fraudulent activities to secure licensure for an applicant.
What is the signature requirement on the form?
The form must be signed with either an original or electronic signature from the supervisor. Any changes made after the signature must be initialed by the supervisor to verify accuracy and maintain integrity in the information provided.
How does this form integrate into the larger application process?
The completed Clinical Social Experience Verification form must be submitted alongside the application for licensure. It plays a critical role in the overall assessment of the applicant's qualifications and readiness to practice as a licensed clinical social worker in California.
Common mistakes
Completing the Clinical Social Experience Verification form is a critical step in the application process for licensure. Mistakes made during this process can lead to delays or even denial of the application. One common error is failing to use a separate form for each supervisor and employer. Each distinct employment experience requires its own verification form. By neglecting to adhere to this guideline, applicants may unintentionally provide incomplete documentation.
Another frequent oversight is not ensuring that the form is both complete and accurate prior to signing. It is imperative that all sections are filled out thoroughly, including providing correct dates and the total hours worked. If any part of the form is missing or contains inaccuracies, this could hinder the review process. Supervisors should be diligent in verifying their responses to avoid this pitfall.
A third mistake occurs when applicants provide an original signature but fail to have the signer initial any changes that were made. Any amendments to the document must be clearly indicated and acknowledged by the supervisor to maintain the integrity and trustworthiness of the information presented. This failing to document changes can raise unnecessary questions during the verification process.
Additionally, applicants sometimes neglect to document the average hours worked per week accurately. The maximum limit is 40 hours, and miscalculating these figures can impact the total experience claimed. Moreover, this may result in discrepancies when cross-referencing against other documented hours provided in the form.
Another oversight involves the verification of face-to-face clinical hours. Applicants must ensure they meet the minimum requirement of 750 hours in individual or group psychotherapy. This figure is crucial to demonstrating the depth of their clinical experience. When applicants fail to distinguish which hours qualify, they risk leaving their application vulnerable to rejection.
Furthermore, there may be a lack of clarity regarding the supervisory relationship. If a supervisor was not employed by the supervisee's employer, a written agreement pertaining to oversight must be included. Failing to provide this documentation can compromise the verification process and lead supervisors to have their authority questioned.
Lastly, many applicants underestimate the importance of accurate and complete reporting of all required hours of direct client contact and supervision. Totaling hours inaccurately or misunderstanding the distinctions between different types of hours can lead to significant errors in the report. Therefore, taking the time to ensure clarity in each section is essential for a successful application.
Documents used along the form
When applying for licensure as a clinical social worker, several key forms and documents are often required in addition to the Clinical Social Experience Verification form. Each of these documents serves a specific purpose in the application process. Below is a list of commonly used forms that should be submitted along with the Clinical Social Experience Verification form.
- Application for Licensure: This primary form initiates the licensure process. It collects essential personal information, educational background, and details about the applicant’s clinical experience.
- Supervisor Agreement Form: This document outlines the relationship between the applicant and their supervisor. It confirms the qualifications of the supervisor and establishes the expectations and responsibilities of both parties throughout the supervision period.
- Transcripts: Official transcripts from accredited educational institutions are required. They verify that the applicant has completed the necessary coursework for clinical social work practice.
- Post Degree Experience Log: This log is a detailed account of all clinical hours accumulated after obtaining the relevant degree. It tracks the total hours dedicated to various facets of clinical work.
- Background Check Consent Form: This form allows the governing body to conduct a criminal background check on the applicant. It is a standard procedure to ensure the applicant meets the ethical and professional standards of the field.
- Personal Statement: The personal statement offers applicants an opportunity to articulate their motivations, experiences, and suitability for the profession. It provides insights into the applicant's character and professional aspirations.
- Professional References: Applicants must submit a list of references who can vouch for their qualifications and character. These professional references typically include former employers or supervisors who can attest to the applicant’s skills and work ethic.
Completing and submitting these documents is crucial in ensuring a smooth licensure process. Attention to detail in preparation can significantly influence the outcome of one's application for licensure as a clinical social worker.
Similar forms
Internship Verification Form: Similar to the Clinical Social Experience Verification form, this document requires confirmation of the intern's participation in supervised work, outlining hours worked and the type of experiences gained under a supervisor.
Practicum Evaluation Form: This form evaluates a student's practicum experience, collecting detailed feedback from supervisors regarding the student’s development and practice within a clinical setting.
Licensed Professional Counselor Experience Verification: Like the Clinical Social Experience Verification form, it requires a licensed supervisor to confirm the amount and type of clinical hours accrued, ensuring compliance with licensing standards.
Application for Licensure: This comprehensive application collects personal, educational, and professional experience details, similar in function to the experience verification form, which accompanies it as part of the licensure process.
Supervision Agreement: This document outlines the responsibilities and expectations of both the supervisor and supervisee, ensuring clarity in the supervision relationship much like the verification form's emphasis on oversight.
Clinical Experience Log: A detailed record of the hours and types of clinical experiences gained, mirroring the tracking and reporting requirements found in the verification form.
Field Placement Assessment: This form assesses the overall quality and educational value of a field placement, similar to how the Clinical Social Experience Verification form reviews the context and quality of the supervisee's experience.
Counselor Supervision Log: This document tracks supervision hours and activities, akin to the verification form’s focus on documenting supervised clinical work.
Verification of Clinical Hours: This form provides documentation of clinical hours required for licensure, reflecting a similar purpose to that of the Clinical Social Experience Verification form.
Dos and Don'ts
When filling out the Clinical Social Experience Verification form, consider the following do's and don'ts:
- Do use a separate form for each supervisor and employer.
- Do ensure all information on the form is complete and accurate before signing.
- Do provide an original or electronic signature and initial any changes made on the form.
- Don't submit the form without verifying that all sections have been filled out correctly.
- Don't forget to attach out-of-state license information if applicable.
- Don't provide false information, as this may lead to denial of your application.
Misconceptions
The Clinical Social Experience Verification form is an essential document for applicants seeking licensure in the field of clinical social work. However, several misconceptions about this form can cause confusion. Here are five common misunderstandings:
- Misconception 1: Any form of supervision qualifies.
- Misconception 2: Incomplete forms are acceptable as long as they are submitted on time.
- Misconception 3: This form does not need to be signed.
- Misconception 4: The number of supervised weeks is not crucial.
- Misconception 5: Supervisors do not need to be licensed.
Not all supervisory experiences are acceptable. The supervisor must have oversight responsibilities and should adhere to the standards set by the Board of Behavioral Sciences.
An incomplete or incorrect form may lead to application denial. Ensure that all sections are filled out completely and accurately before submission.
The form requires an original or electronic signature from the supervisor. Signatures certify the accuracy of the information provided.
The applicant must have a minimum of 104 weeks of supervised experience. This minimum is essential to meet state requirements.
Supervisors must hold relevant licensure and meet specific criteria to ensure they provide adequate guidance and oversight to the applicant.
Understanding these misconceptions can help applicants navigate the licensing process more effectively and avoid potential setbacks in their applications.
Key takeaways
The Clinical Social Experience Verification form is essential for individuals applying for licensure as clinical social workers in California. Here are key takeaways to consider when filling out and using the form:
- Separate Forms: Use a distinct form for each supervisor and employer to ensure clarity.
- Accuracy is Crucial: Ensure all information is complete and correct before signing the document.
- Signatures Required: Provide an original or electronic signature. Initial any changes that are made.
- Compliance Check: Confirm that the setting lawfully provides clinical social work or similar services.
- Oversight Verification: The supervisor must verify that the ASW's work meets experience and supervision standards.
- Supervisor’s Information: Include accurate details about the supervisor, such as their license type and number.
- Supervised Experience: Ensure at least 104 weeks of supervised experience is documented.
- Minimum Hour Requirements: Document a minimum of 2,000 hours in clinical psychosocial diagnosis and treatment.
- Face-to-Face Hours: At least 750 of the total hours should include direct face-to-face interactions.
- Document Everything: Keep thorough records, as all information provided may be subject to verification.
Following these guidelines will help in completing and submitting the Clinical Social Experience Verification form effectively.
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