Form 4B - Certification of Experience for Licensed Clinical Social Worker

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) 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.