LCSW Application Forms

Instructions for completing and submitting the forms required for licensure appear below. You may also need to submit additional information (for example, examination scores). Please refer to the license requirements link on the left for complete information regarding all requirements you must meet.

Note: All forms are in Adobe Portable Document Format (PDF). To view or print these documents, you will need to have the free Adobe Reader External Link Icon installed on your computer. Download times and print quality will depend on your connection speed and printer.

Please type or print all information and sign all forms in black or blue ink. Original signatures are required on all forms.

Complete Application Packet
All forms and instructions in a single PDF file - Licensed Clincial Social Worker Licensing Application Packet ( PDF 184 KB)

Individual Application Forms

Form 1 - Application for Licensure - ( PDF 29 KB)

Important Notice: A New York State professional license is valid for life unless it is revoked, annulled, or suspended by the Board of Regents. To practice in New York State your professional license must be registered. If your registration has lapsed and you need to reregister, do not submit a Form 1. Instead, contact the Registration and Fees Unit to request a Delayed Registration Application by e-mailing: OPREGFEE@nysed.gov, or by calling 518-474-3817 Ext. 410.  When e-mailing, be sure to include your profession, license number, address on record, new address (if changed), date of birth and the last 4 digits of your SSN.

All applicants for licensure must complete this form and submit it with the $294 licensure and first registration fee directly to the Office of the Professions at the address at the end of Form 1. Make checks payable to the New York State Education Department. NOTE: Your cancelled check is your receipt.

You must answer all questions and provide all information requested unless otherwise indicated. Failure to complete all required parts of the application will delay its review. Your signature on Form 1 must be notarized by a Notary Public.

Address/Name Change Form - Optional ( PDF 22 KB)
You are required to notify us within 30 days of any name or address changes. Please read the instructions and complete the appropriate sections of this form.
 
Form 2 - Certification of Professional Education - ( PDF 20 KB)
This form must be submitted directly by the educational institution(s) you attended. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section before sending the entire form to your school. Be sure to sign and date item 9.
  • Section II: The Registrar must complete this section and return both pages of the form in an official school envelope with requested documents directly to the Office of the Professions at the address at the end of the form.

If you attended a social work program not registered as licensure qualifying by the New York State Education Department, you must also ask your school to submit an official transcript or marksheets.

Please photocopy this form as needed.

Form 3 - Verification of Other Professional Licensure/Certification - ( PDF 18 KB)

Complete this form if you hold, or ever held, a license or certificate to practice any profession* in any jurisdiction.

This form must be submitted directly by the licensing/certifying authority. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section before sending the entire form to the licensing/certifying authority of each jurisdiction in which you are or have been licensed/certified. Be sure to sign and date item 8.
  • Section II: The licensing/certifying authority must complete this section, sign, date and return both pages of the form directly to the Office of the Professions at the address at the end of the form.

NOTE: A Form 3 is not required for licenses/certificates issued by the New York State Education Department.

*Profession is defined as professional titles licensed under New York State Education Law. (See page 2 of the Address/Name Change Form ( PDF 22 KB) for a list of those titles.)

Appendix A - Requirements for Supervised Experience - ( PDF PDF )
Send this document to the licensed professional(s) who supervised your experience or will supervise your practice under a limited permit along with the form you are asking them to complete.
 
Form 4 - Applicant Experience Record - ( PDF 11 KB)
Complete and send both pages of this form directly to the Office of the Professions at the address at the end of the form. Be sure to sign and date item 10.

You must also complete a separate Form 4B for each supervised experience you list on the Applicant Experience Record (Form 4).

Form 4B - Certification of Experience for Licensed Clinical Social Worker - ( PDF 23 KB)
This form must be submitted directly by the supervisor. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section and send the entire form and a copy of Appendix A (HTML | PDF PDF ) to your supervisor. If your supervisor is deceased, a licensed professional colleague may submit this form to verify your supervised experience. Be sure to sign and date item 7.
  • Section II: The supervisor must complete this section, sign and date the form and return the entire form directly to the Office of the Professions at the mailing address at the end of the form. If the supervisor is deceased the Form 4B may be completed by an LCSW who must provide the qualifications of the supervisor, the dates and frequency of the supervision, and attest to the accuracy of the information and the applicant's supervised experience.

The psychotherapy log should be completed weekly to record client contact hours and supervision hours. The completed log should be retained by the qualified supervisor who is responsible for the client contact hours and supervision of the applicant. The State Board for Social Work may request the supervisor to submit the completed log to clarify supervised experience.

Please photocopy this form as needed but all forms submitted must bear original signatures and be notarized by a Notary Public.

Form 4E - Endorsement Applicant Experience Record - ( PDF 14 KB)
This form is for applicants seeking licensure in New York State by endorsement of a license to practice clinical social work issued in another jurisdiction. You must have at least 10 years of licensed experience in clinical social work, in the 15 year period prior to applying for licensure in New York State.

Complete and send both pages of this form directly to the Office of the Professions at the address at the end of the form. Be sure to sign and date item 9.

You must also complete a separate Form 4F for each colleague you list on the Endorsement Applicant Experience Record (Form 4E).

Form 4F - Certification of Licensed Experience - ( PDF 19 KB)
This form is for applicants seeking licensure in New York State by endorsement of a license to practice clinical social work issued in another jurisdiction. You must have at least 10 years of licensed experience in clinical social work, in the 15 year period prior to applying for licensure in New York State.

This form must be submitted by the licensed colleague who is attesting to your experience as a licensed clinical social worker in another jurisdiction. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section and send the entire form to the licensed colleague who will attest to your experience as a licensed clinical social worker in another jurisdiction. Be sure to sign and date item 6.
  • Section II: The licensed colleague who will attest to your licensed experience must complete this section and return both pages of the form directly to the Office of the Professions at the address at the end of the form.

A separate Form 4F must be submitted for each licensed colleague listed on the Endorsement Applicant Experience Record (Form 4E)

Form 4Q - Approval of Qualifications to Supervise Psychotherapy - ( PDF 20 KB)
This form must be submitted directly by the supervisor. The Office of the Professions will not accept this form if submitted by the applicant.

This form must be submitted if your supervisor is not an LCSW or has not already been approved by the State Education Department to supervise the provision of psychotherapy services by an LMSW.

  • Section I: Complete this section before giving the entire form and a copy of Appendix A ( PDF PDF 10 KB) to your supervisor.
  • Section II: Your supervisor must complete this section, sign the attestation, have the signature notarized by a Notary Public, and return both pages of this form directly to the Office of the Professions at the address at the end of the form.

Please photocopy this form as needed but all forms submitted must bear original signatures and be notarized by a Notary Public.

NOTE: The supervisor may submit the Form 4Q prior to supervising your experience. Approval of the supervisor does not guarantee approval of the applicant's experience which must be completed in accordance with the requirements in the Commissioner's Regulations.

Form 5 - Application for Limited Permit - ( PDF 20 KB)
  • Section I: Complete this section before giving the entire form and a copy of Appendix A ( PDF PDF 10 KB) to your prospective employer. Be sure to sign and date item 9.
  • Section II: Your prospective supervisor must complete this section, sign the attestation, and have the signature notarized by a Notary Public.

Return the completed form with the $70 fee to the Office of the Professions at the mailing address at the end of the form.

Form 6 - Plan for Supervised Experience - ( PDF 22 KB)
This form must be submitted by the supervisor. The Office of the Professions will not accept this form if submitted by the applicant.
  • Section I: Complete this section and send the entire form and a copy of Appendix A to your proposed supervisor. Be sure to sign and date item 7.
  • Section II: The proposed supervisor must complete this section and return the entire form to the Office of the Professions at the address at the end of the form.

Child Abuse Certification of Exemption Form ( PDF 17 KB)
This form is not for all applicants. Use this form only if you are applying for an exemption to the requirement to complete training or coursework in the identification and reporting of child abuse because your practice does not involve professional contact with persons under the age of 18 and persons 18 or older with a handicapping condition who reside in a residential care school or facility.
Last Updated: April 9, 2014