The Clinical Social Experience Verification form is a crucial document used in California to validate the clinical experience of aspiring social workers. This form must be completed by a supervisor and submitted alongside the application for licensure, ensuring that all experience meets the necessary requirements. By providing a structured way to verify hours and supervision, it supports the integrity of the licensing process in the field of social work.
The Clinical Social Experience Verification form is a crucial document for aspiring clinical social workers in California, serving as a bridge between academic training and professional practice. This form is designed to capture essential information about an applicant's supervised clinical experience, ensuring that it meets the state's licensing requirements. Applicants must have their supervisors complete the form, providing details about the work setting, oversight, and the nature of the clinical experience gained. Key components include verification of the employer's compliance with legal standards for providing clinical social work, as well as specifics about the supervision received, including hours worked, types of supervision, and the nature of clinical services provided. The form also emphasizes the importance of accurate reporting, as any discrepancies or false information can lead to serious consequences, including denial of licensure. With a structured approach, the form guides both the applicant and supervisor through the verification process, helping to ensure that future clinical social workers are well-prepared to meet the needs of their clients.
What is the purpose of the Clinical Social Experience Verification form?
The Clinical Social Experience Verification form is essential for individuals seeking licensure as clinical social workers in California. It serves to verify the supervised experience of an Associate Social Worker (ASW) under a qualified supervisor. This form must be completed accurately and submitted with the application for licensure to ensure that all requirements are met.
Who is responsible for completing the form?
The supervisor of the ASW is responsible for completing this form. Each supervisor must fill out a separate form for their respective ASW. It is crucial that the supervisor provides all requested information, signs the form, and initials any changes to ensure its validity.
What information is required from the supervisor on the form?
The supervisor must provide their name, contact information, license type, license number, and the date they were first licensed. Additionally, they need to indicate whether they were employed by the ASW’s employer and if they had a written agreement regarding the oversight of the supervisee. This information helps establish the supervisor's qualifications and the legitimacy of the supervisory relationship.
What are the minimum experience requirements that must be documented?
What happens if incorrect or incomplete information is provided?
Providing false information or omitting important details can lead to serious consequences, including the denial of the application for licensure. The Board of Behavioral Sciences has the authority to take disciplinary action against any licensee who assists an applicant in obtaining a license through fraud or deceit. Therefore, it is imperative that all information is accurate and complete before submission.
When filling out the Clinical Social Experience Verification form, consider the following key points:
Misconception 1: The Clinical Social Experience Verification form is optional for licensure.
This form is not optional. It is a crucial part of the application process for becoming a licensed clinical social worker in California. Applicants must ensure that this form is completed accurately and submitted along with their application for licensure.
Misconception 2: Only one form is needed, regardless of the number of supervisors.
Each supervisor must complete a separate Clinical Social Experience Verification form. This requirement ensures that all experiences are documented and verified by the appropriate supervising professionals, providing a comprehensive overview of the applicant's clinical experience.
Misconception 3: The form can be signed without any verification of the information provided.
Signatures on this form require careful verification of all information. The supervisor must ensure that the details are complete and accurate before signing. Any changes made must be initialed by the supervisor to maintain the integrity of the document.
Misconception 4: The hours of experience reported do not need to meet specific minimum requirements.
Applicants must meet strict minimum hour requirements for various categories of experience. For instance, a minimum of 3,000 total hours is required, with specific minimums for supervised weeks, individual or group psychotherapy, and supervision hours. Failing to meet these requirements can lead to delays or denial of licensure.
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)
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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
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Aoausa - Contact information is requested, including home phone, cell phone, and email address.
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Incomplete Information: One common mistake is failing to fill out all required fields. Each section must be completed, including the applicant's name, ASW number, and employer information. Leaving any part blank can lead to delays in processing your application.
Incorrect Supervisor Details: Providing inaccurate information about the supervisor can create complications. Ensure that the supervisor's name, license type, and license number are correct. Double-check these details before submitting the form.
Missing Signatures: A signature is crucial. The form must be signed by the supervisor, and any changes made should be initialed. Without a valid signature, the form may be considered invalid.
Omitting Required Documentation: If the supervisor has been licensed in California for less than two years, it is essential to attach the out-of-state license information. Failing to include this documentation can result in application denial.
Inaccurate Hours Reporting: Misreporting the total hours of supervised experience can lead to significant issues. Make sure to calculate and report the hours accurately, adhering to the minimum and maximum requirements specified on the form.
When filling out the Clinical Social Experience Verification form, it's important to ensure accuracy and completeness. Here are seven key dos and don'ts to keep in mind:
The Clinical Social Experience Verification form shares similarities with the Employment Verification form, which is commonly used across various industries. Both documents require a supervisor or employer to confirm the details of an individual's work experience. They emphasize the need for accurate completion and often necessitate a signature for validation. In both cases, the verification serves to establish the legitimacy of the applicant's experience, ensuring that it meets the necessary standards for professional licensure or employment.
Another document comparable to the Clinical Social Experience Verification form is the Supervision Agreement. This agreement outlines the terms of supervision between a supervisee and their supervisor. Like the verification form, it details the supervisory relationship, including the responsibilities of both parties. It often includes sections that require signatures to affirm that the supervisory arrangement is understood and agreed upon, thus ensuring accountability in the professional development process.
The Internship Verification form is also similar in purpose and structure. This document is used to confirm the completion of an internship program, requiring supervisors to attest to the intern's performance and hours worked. Both forms require detailed information about the applicant’s experience and necessitate a supervisor’s signature to validate the claims made. This ensures that the intern's experience aligns with the required competencies for their field.
Additionally, the Professional Experience Verification form serves a similar function. This document is utilized by various licensing boards to confirm an applicant's work history in a specific profession. It requires supervisors to provide information about the applicant's roles and responsibilities. Like the Clinical Social Experience Verification form, it emphasizes the importance of accurate reporting and often includes a signature section to affirm the information provided.
In California, individuals engaging in the sale of all-terrain vehicles (ATVs) must be aware of the importance of maintaining proper documentation to facilitate a smooth transaction. The California ATV Bill of Sale form serves as an essential tool in this process, ensuring that both the buyer and seller are protected legally. By completing this form, sellers can confirm the sale and transfer of ownership while buyers gain the necessary proof for registration. For more details and access to the form, visit https://autobillofsaleform.com/atv-bill-of-sale-form/california-atv-bill-of-sale-form/.
The Certification of Experience form is another document that mirrors the Clinical Social Experience Verification form. This form is often used in educational and professional contexts to verify that an individual has completed a certain level of experience or training. Both forms require a supervisor's endorsement and detailed descriptions of the applicant's work to ensure that they meet the necessary qualifications for certification or licensure.
Moreover, the Training Verification form shares similarities with the Clinical Social Experience Verification form. This document is used to confirm that an individual has completed a specific training program. Both forms require detailed accounts of the training or experience gained, along with a supervisor's signature to validate the information. This ensures that the applicant has received the necessary education or training to perform their professional duties effectively.
The Reference Verification form also parallels the Clinical Social Experience Verification form in its intent. This document is often used to confirm the qualifications and experiences of a job applicant. Like the verification form, it requires a supervisor or reference to provide a signature and confirm the applicant's work history. This process helps to establish the credibility of the applicant's experience and qualifications for potential employers or licensing boards.
In addition, the Clinical Training Verification form is similar in that it is used to confirm clinical training experiences. This document requires supervisors to attest to the training hours completed and the skills acquired during the training period. Both forms emphasize the importance of accurate reporting and require a supervisor's signature to validate the information, ensuring that the applicant has met the necessary training requirements for their field.
Lastly, the Licensure Application form itself bears resemblance to the Clinical Social Experience Verification form. While the licensure application encompasses a broader range of information, it still requires verification of work experience and training. Both documents necessitate accurate details and supervisor signatures to confirm the applicant's qualifications, ensuring that they meet the standards set forth by the licensing board.