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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 experience was completed outside of New York State. If your supervisor is licensed by the State Education Department to supervise the provision of psychotherapy services by an LMSW, the Form 4Q is not required.

  • Section I: Complete this section before giving the entire form and a copy of Appendix A ( PDF 10 KB) to your supervisor.
  • Section II: Your supervisor must complete this section, sign the attestation, 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.