Blank Clinical Social Experience Verification Template

The Clinical Social Experience Verification form is a crucial document for aspiring clinical social workers in California. It verifies the supervised experience necessary for licensure, ensuring that applicants meet the required standards of practice. Completing this form accurately is essential for a smooth application process, so make sure to fill it out by clicking the button below.

Article Structure

The Clinical Social Experience Verification form plays a crucial role in the licensure process for aspiring clinical social workers in California. This form must be completed by the applicant's supervisor, ensuring that all necessary details are accurately provided. Each supervisor and employer requires a separate form, emphasizing the need for thoroughness. The applicant's name and ASW number must be clearly indicated, along with the employer's information, including the name, address, and contact details. Key questions assess whether the setting lawfully provided clinical social work services and if proper oversight was maintained during the applicant's experience. Supervisors must provide their credentials, including license type and number, while also confirming their employment status in relation to the supervisee. The experience section requires specific data on the duration of supervision, total hours spent in various types of supervision, and the clinical hours accrued. Accurate reporting of these metrics is essential, as they must meet minimum requirements set forth by the Board of Behavioral Sciences. The form concludes with a signature from the supervisor, underscoring the importance of integrity in the application process, as any discrepancies or omissions may lead to serious consequences for the applicant.

Form Sample

37A-201 (Revised 01/2022) 1 of 2

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:

o Use a separate form for each supervisor and

employer

o Make sure this form is complete and correct

prior to signing

o Provide an original or electronic

signature and have the signer initial

any changes

o Submit 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) 2 of 2

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

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,

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?

Yes

*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

⇩ PDF

Document Specifications

Fact Name	Detail
Governing Agency	The form is managed by the California Board of Behavioral Sciences.
Purpose	This form verifies clinical social work experience for Associate Social Workers (ASWs) in California.
Submission Requirement	Applicants must submit this form along with their Application for Licensure.
Supervision Details	Supervisors must complete a separate form for each supervisee and employer.
Experience Hours	A minimum of 3,000 hours of supervised experience is required for licensure.
Signature Requirement	The supervisor's original or electronic signature is mandatory on the form.
False Information Penalty	Providing false information may lead to application denial or disciplinary action.

Completing the Clinical Social Experience Verification form is a crucial step in the licensure process for social workers. Ensuring accuracy and completeness is vital, as any errors may delay your application. Follow these steps carefully to fill out the form correctly.

Obtain the Clinical Social Experience Verification form from the Board of Behavioral Sciences website or your supervisor.
Fill in your name and ASW number at the top of the form.
Provide your employer's information, including the name, telephone number, and address (number and street, city, state, and zip code).
Answer the first two questions regarding the legality and oversight of your work setting by selecting either "Yes" or "No."
Complete the supervisor information section, including the supervisor's name, telephone number, email address (optional), license type, license number, and the state in which they are licensed.
Indicate the date the supervisor was first licensed. If applicable, provide the certification number for Psychiatry.
State whether the supervisor was employed by your employer and, if not, confirm if a written agreement was signed.
Fill in the dates of your experience, using the format mm/dd/yyyy.
Provide the total supervised weeks, total hours in individual or triadic supervision, total hours in group supervision, average hours worked per week, and total hours of clinical psychosocial diagnosis, assessment, and treatment.
Specify how many hours were spent in face-to-face individual or group psychotherapy/counseling.
Complete the total hours of client-centered advocacy, consultation, evaluation, research, workshops, seminars, training sessions, or conferences, as well as direct supervisor contact.
Calculate the total hours of experience and ensure they meet the minimum requirements.
Answer the question regarding additional supervision hours for weeks with more than 10 hours of direct clinical counseling.
Have your supervisor sign the form and date it. Ensure that the signature is original or electronic and that any changes are initialed.
Review the completed form for accuracy and completeness before submission.
Submit the signed form along with your Application for Licensure to the Board of Behavioral Sciences.

What is the purpose of the Clinical Social Experience Verification form?

The Clinical Social Experience Verification form is used to confirm the clinical experience of an Associate Social Worker (ASW) under the supervision of a licensed professional. It ensures that the applicant has met the necessary requirements for licensure in California.

Who needs to complete this form?

The form must be completed by the applicant's supervisor. Each supervisor and employer requires a separate form to ensure accurate verification of the ASW’s experience.

What information is needed from the supervisor?

The supervisor must provide their name, contact information, license type, license number, and the date they were first licensed. If applicable, they must also indicate if they were certified in Psychiatry during the supervision period.

What are the experience requirements outlined in the form?

The applicant must document a minimum of 3,000 hours of clinical experience, including at least 2,000 hours of clinical psychosocial diagnosis, assessment, and treatment. Additionally, 750 hours must be in face-to-face individual or group psychotherapy or counseling.

How should the form be submitted?

The completed form should be submitted along with the Application for Licensure. Ensure that it is signed by the supervisor and that any changes are initialed. Both original and electronic signatures are acceptable.

What happens if false information is provided?

Providing false information or omitting important details may lead to denial of the application. The Board of Behavioral Sciences can take disciplinary action against any licensee involved in fraudulent practices related to the application.

Is there a deadline for submitting this form?

While the form does not specify a deadline, it is crucial to submit it promptly with your application to avoid delays in the licensure process. Timely submission ensures that your experience is verified and considered in a timely manner.

Common mistakes

Not using separate forms for each supervisor and employer: It's essential to fill out a distinct form for every supervisor and employer to ensure clarity and accuracy in your experience verification.
Failing to check for completeness: Before signing, double-check that all sections of the form are filled out completely and accurately. Incomplete forms can lead to delays or denials.
Not providing original or electronic signatures: Ensure that the supervisor provides a valid signature. Any changes made to the form must also be initialed by the signer.
Incorrectly reporting experience dates: Be precise when entering the dates of experience. The format should be mm/dd/yyyy, and any errors can result in issues with your application.
Miscalculating total hours: It's crucial to accurately calculate and report total hours for supervision and clinical work. Double-check your math to avoid discrepancies.
Omitting supervisor information: Provide complete details about the supervisor, including name, contact information, and license type. Missing information can hinder the verification process.
Not adhering to minimum and maximum hour requirements: Familiarize yourself with the minimum and maximum hours required for various categories of supervision and experience. Ensure your reported hours meet these criteria.
Ignoring the need for additional supervision hours: If you worked more than 10 hours of direct clinical counseling in a week, remember to account for the required additional supervision hours.
Providing false or misleading information: It's crucial to be honest and transparent when filling out the form. Providing incorrect information can lead to serious consequences, including application denial.

Documents used along the form

When applying for licensure as a Clinical Social Worker, several important documents accompany the Clinical Social Experience Verification form. Each of these documents plays a crucial role in ensuring that your application is complete and meets the necessary requirements. Below are some commonly used forms that you may need to submit along with your verification form.

Application for Licensure: This is the primary document that formally requests your license to practice as a Clinical Social Worker. It includes your personal information, educational background, and details about your supervised experience.
Supervision Agreement: If your supervisor is not employed by your agency, this document outlines the terms of oversight. It ensures that both parties understand their responsibilities regarding supervision.
Out-of-State License Verification: If you hold a license from another state, this form confirms its validity. It is required if you have been licensed in California for less than two years at the time of your application.
Personal Statement: This document allows you to explain your professional journey, motivations for becoming a Clinical Social Worker, and any relevant experiences that shaped your career path.

Submitting all necessary forms accurately and promptly is essential to avoid delays in the licensure process. Ensure that each document is complete and signed where required to facilitate a smooth review of your application.

Similar forms

The Clinical Social Experience Verification form shares similarities with the Supervised Experience Verification form used by various professional licensing boards. Both documents require a supervisor to validate the experience of the applicant in a clinical setting. They typically include sections for the supervisor's information, the applicant's details, and specific questions regarding the nature of the supervision and the clinical work performed. The goal of both forms is to ensure that the applicant has met the necessary requirements for licensure, confirming that they have received adequate oversight and training during their supervised experience.

Another document that resembles the Clinical Social Experience Verification form is the Internship Verification form commonly used in educational settings. This form is designed to confirm that students have completed their required internships under appropriate supervision. Similar to the Clinical Social Experience Verification form, it asks for details about the supervisor, the nature of the internship, and the hours worked. Both documents serve to ensure that the experiences gained are relevant and meet the standards set by the respective licensing or educational bodies.

The Experience Verification form for Marriage and Family Therapists (MFT) is also comparable to the Clinical Social Experience Verification form. This document requires supervisors to attest to the clinical experience of MFT applicants. Like the Clinical Social Experience Verification form, it includes sections for supervisor and applicant information, as well as questions about the type of clinical work performed. Both forms emphasize the importance of supervision in developing the skills necessary for effective practice in the mental health field.

Lastly, the Professional Experience Verification form used for Licensed Professional Clinical Counselors (LPCC) is similar in structure and purpose. This form requires documentation of the applicant's supervised clinical experience and is completed by a qualified supervisor. Both forms contain sections for essential details such as the duration of supervision, hours of clinical work, and the nature of the counseling provided. The purpose of these forms is to ensure that applicants have met the required standards for licensure and have received appropriate guidance during their training.

Dos and Don'ts

When completing the Clinical Social Experience Verification form, attention to detail is crucial. Here are four important do's and don'ts to consider:

Do use a separate form for each supervisor and employer.
Do ensure the form is complete and correct before signing.
Don't forget to provide an original or electronic signature, and make sure to initial any changes.
Don't submit the form without confirming that all required information is accurately filled out.

By adhering to these guidelines, you can help ensure a smoother verification process and avoid potential issues with your application.

Misconceptions

Misconception 1: The Clinical Social Experience Verification form is optional.

This form is a crucial part of the application for licensure. It verifies the supervised experience that applicants have gained, ensuring they meet the necessary requirements to practice legally.
Misconception 2: Only one form is needed for multiple supervisors.

Each supervisor must complete a separate form. This ensures that the experience from each supervisor is accurately documented and verified.
Misconception 3: The supervisor does not need to be licensed.

The supervisor must hold a valid license relevant to the field. This is essential to ensure that the guidance and oversight provided meet professional standards.
Misconception 4: The applicant can submit a form without a supervisor's signature.

An original or electronic signature from the supervisor is required. This signature confirms the accuracy of the information provided and the supervisor's agreement with the applicant's claimed experience.
Misconception 5: All hours of experience count equally.

Not all hours are treated the same. Specific minimums exist for different types of supervision and clinical work, ensuring a well-rounded experience in various aspects of social work.
Misconception 6: The form can be submitted after the application.

The verification form must accompany the application for licensure. Submitting it separately can lead to delays or complications in the application process.

Key takeaways

When completing the Clinical Social Experience Verification form, it is essential to follow specific guidelines to ensure accuracy and compliance. Here are six key takeaways:

Use separate forms for each supervisor and employer. Each supervisor must complete an individual form to provide a clear record of experience.
Ensure completeness and correctness. Review the form thoroughly before signing to avoid any omissions or errors.
Obtain original or electronic signatures. The supervisor must sign the form, and any changes should be initialed by them.
Submit the form with your application. This verification form is a necessary component of the application for licensure.
Be aware of experience requirements. The form requires specific details, including total supervised weeks and hours of supervision.
Understand the consequences of false information. Providing inaccurate information may lead to application denial or disciplinary action.

By adhering to these guidelines, applicants can facilitate a smoother verification process for their clinical social work experience.