⇨

Blank Clinical Social Experience Verification PDF Form

The Clinical Social Experience Verification form is a document required by the California Board of Behavioral Sciences to confirm an applicant's supervised experience in clinical social work. This form must be completed by the applicant's supervisor and submitted as part of the licensure application process. Ensure all sections are filled out accurately to facilitate a smooth application experience by clicking the button below to fill out the form.

Article Guide

For those pursuing a career in clinical social work in California, the Clinical Social Experience Verification form is a crucial step in the licensure process. This form serves as a detailed record of an applicant's supervised experience, ensuring that they have met the necessary requirements to practice competently and ethically. Each applicant must have their supervisor complete a separate form for every employer, emphasizing the importance of accurate and thorough documentation. The form captures essential information such as the applicant's name, employer details, and the supervisor's credentials, along with a series of questions designed to verify the legitimacy of the clinical setting and the nature of the supervision provided. It also outlines specific requirements regarding the number of supervised weeks, hours of individual and group supervision, and the total hours dedicated to clinical work, including psychotherapy and client advocacy. Importantly, the form mandates that supervisors provide original or electronic signatures, reinforcing the accountability of both the applicant and the supervisor. By ensuring that all information is complete and accurate, applicants can avoid potential pitfalls that may arise from misrepresentation, which could jeopardize their path to licensure.

Document Preview

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

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

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

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)

1 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						A.
		individual or group psychotherapy / counseling (Minimum 2,000 overall):					A.


	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						Yes
	additional hours of face-to-face group supervision provided for every week in which more							No
	than 10 hours of direct clinical counseling was performed?							No
	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
37A-201 (Revised 01/2022)	2 of 2

➤ PDF File

Form Specifications

Fact Name	Details
Governing Body	The Clinical Social Experience Verification form is governed by the Board of Behavioral Sciences in California.
Supervisor Requirement	Each supervisor must complete a separate form for the applicant.
Signature Requirement	An original or electronic signature is required, along with initials for any changes made.
Experience Verification	The form verifies that the setting provided lawful clinical social work and met supervision requirements.
Minimum Supervised Weeks	A minimum of 104 supervised weeks is required for the experience to be valid.
Total Clinical Hours	A total of at least 3,000 hours of experience is required, including specified minimums for various categories.
Face-to-Face Requirement	At least 750 hours must be gained through face-to-face individual or group psychotherapy.
False Information Consequence	Providing false information may lead to application denial and disciplinary action against the licensee.
Contact Information	Applicants must provide their employer's name, address, and telephone number on the form.

Completing the Clinical Social Experience Verification form is an important step in your application process. This form needs to be filled out accurately to ensure that your clinical experience is properly documented. Follow the steps below to complete the form correctly.

Begin by entering your name and ASW number at the top of the form.
Fill in your employer's information, including the name, telephone number, and address.
Answer the first two questions regarding the setting where you gained your experience. Indicate whether the setting lawfully provided clinical social work and whether it provided oversight for your work.
Provide your supervisor's information, including their name, telephone number, email address, license type, license number, and the state where they are licensed.
Indicate whether your supervisor was employed by your employer. If not, confirm whether a written agreement was signed regarding oversight.
Document the dates of your experience by entering the start and end dates in the provided fields.
Complete the experience information section by filling in the total supervised weeks, total hours in individual or triadic supervision, total hours in group supervision, and average hours worked per week.
Record the total hours of clinical psychosocial diagnosis, assessment, and treatment, including the hours spent in individual or group psychotherapy/counseling.
Fill in the total hours for client-centered advocacy, consultation, evaluation, research, workshops, seminars, training sessions, or conferences.
Calculate the total hours of experience and ensure they meet the minimum requirements.
Answer the question about additional supervision hours based on your direct clinical counseling hours.
Have your supervisor sign and date the form, ensuring that they provide an original or electronic signature and initial any changes made.
Review the completed form for accuracy before submission.

Once you have filled out the form, you will need to submit it along with your application for licensure. Ensure that all information is accurate and complete to avoid any delays in the processing of your application.

Your Questions, Answered

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

The Clinical Social Experience Verification form is designed to confirm the clinical social work experience of an Associate Social Worker (ASW) under the supervision of a licensed professional. This form must be completed by the supervisor and submitted with the ASW's application for licensure. It ensures that the applicant has met the necessary experience and supervision requirements as mandated by the Board of Behavioral Sciences in California.

Who needs to complete the form, and how should it be submitted?

The supervisor of the ASW is responsible for completing the Clinical Social Experience Verification form. Each supervisor must fill out a separate form for every employer. It is essential that the form is complete and accurate before signing. The supervisor must provide either an original or electronic signature and initial any changes made. Once completed, the form should be submitted along with the ASW's application for licensure to the Board of Behavioral Sciences.

What information is required on the form?

The form requires several key pieces of information, including the applicant's name, ASW number, and details about the employer. Supervisors must provide their name, contact information, license type, and license number. Additionally, the form asks for specific experience metrics, such as the total supervised weeks, hours of supervision, and hours spent on clinical work. This data helps the Board verify that the ASW has fulfilled the necessary requirements for licensure.

What happens if false information is provided on the form?

Providing false information or omitting important details on the Clinical Social Experience Verification form can lead to serious consequences. The Board of Behavioral Sciences may deny the application for licensure based on this misconduct. Furthermore, disciplinary actions may be taken against any licensee who assists an applicant in obtaining a license through fraud or misrepresentation. All submitted information is subject to verification, emphasizing the importance of accuracy and honesty.

Common mistakes

Neglecting to Use Separate Forms for Different Supervisors

One common mistake is using a single form for multiple supervisors. Each supervisor must complete their own form to ensure accurate verification of experience. This helps maintain clarity and allows the Board to assess each supervisor's input independently.
Failing to Double-Check for Completeness and Accuracy

Before signing, it's crucial to review the form thoroughly. Omitting information or making errors can lead to delays or even denial of the application. All sections must be filled out correctly to avoid complications down the line.
Not Providing an Original or Electronic Signature

Some applicants forget that a valid signature is required. Whether it's an original or electronic signature, this step is essential. Additionally, any changes made to the form should be initialed by the signer to maintain integrity.
Ignoring the Importance of Accurate Experience Dates

Dates of experience must be filled out correctly. Misreporting the duration of clinical work can lead to discrepancies that may raise red flags during the review process. It's vital to ensure that the dates align with the claimed hours of experience.

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 forms plays a vital role in confirming your qualifications and experience. Below is a list of commonly required documents.

Application for Licensure: This is the primary document submitted to the Board of Behavioral Sciences. It includes personal information, educational background, and details about supervised experience.
Official Transcripts: These documents provide proof of your educational qualifications. They must be sent directly from your educational institution to the Board.
Supervisor Agreement: If your supervisor is not employed by your employer, this agreement outlines the terms of oversight and responsibilities. It must be signed by both parties.
Verification of Experience Form: This form confirms the total hours of supervised experience and must be completed by your supervisor. It details the nature of the clinical work performed.

Gathering these documents carefully will help streamline the application process. Ensure that all information is accurate and complete before submission to avoid delays. Your diligence in this matter is crucial for a successful application.

Similar forms

Employment Verification Letter: This document confirms an individual's employment history, including dates of employment and job duties. Like the Clinical Social Experience Verification form, it requires verification from a supervisor or employer.
Internship Verification Form: Similar to the Clinical Social Experience Verification form, this document verifies the completion of an internship, detailing hours worked and responsibilities undertaken during the internship period.
Supervisor Evaluation Form: This form is used to evaluate an individual's performance under supervision. It shares the requirement for a supervisor's signature and assessment, much like the Clinical Social Experience Verification form.
Professional Experience Verification Form: This document verifies professional experience in a specific field. It also requires detailed information about the supervisor and the nature of the work, similar to the clinical verification process.
Licensure Application Form: This form is essential for applying for professional licensure. It often requires proof of supervised experience, mirroring the verification needed in the Clinical Social Experience Verification form.
Certification of Supervised Practice: This document certifies that an individual has completed a specific number of hours of supervised practice. It is akin to the Clinical Social Experience Verification form in that it requires detailed reporting of hours and activities.
Continuing Education Verification Form: This form confirms that an individual has completed required continuing education courses. Like the Clinical Social Experience Verification form, it often requires signatures and verification from course providers.
Field Placement Verification Form: Used in academic settings, this form verifies that a student has completed required field placement hours. It shares similarities with the Clinical Social Experience Verification form in that both require documentation of hours and supervisor approval.
Clinical Supervision Agreement: This document outlines the terms of supervision between a supervisor and a supervisee. It is similar to the Clinical Social Experience Verification form in that it establishes the supervisory relationship and expectations.
Practicum Experience Verification Form: This form verifies the completion of practicum experiences in educational programs. It requires detailed information about the experience and supervision, much like the Clinical Social Experience Verification form.

Dos and Don'ts

When filling out the Clinical Social Experience Verification form, attention to detail is crucial. Here are ten important dos and don’ts to keep in mind:

Do use a separate form for each supervisor and employer.
Do ensure that all information provided is complete and accurate before signing.
Do include an original or electronic signature, and have the signer initial any changes made.
Do submit the form along with your Application for Licensure.
Do confirm that the setting provided clinical social work or mental health counseling lawfully.
Don’t leave any sections of the form blank; every question must be answered.
Don’t forget to provide the supervisor’s contact information, including phone and email.
Don’t submit the form without verifying that the supervisor meets the licensing requirements.
Don’t attempt to falsify or omit any information; this could lead to serious consequences.
Don’t overlook the importance of documenting all hours and experiences accurately.

Completing this form correctly is essential for your licensure process. Take the time to review each section thoroughly.

Misconceptions

Many people have misunderstandings about the Clinical Social Experience Verification form. Here are six common misconceptions:

It’s only for new applicants. Some believe that this form is only necessary for those applying for licensure for the first time. In reality, it can also be required for those who have previously held a license and are reapplying.
Any supervisor can sign it. Many think that any professional can verify their experience. However, the supervisor must meet specific qualifications and be appropriately licensed to oversee clinical social work.
Electronic signatures are not accepted. Some applicants worry that only handwritten signatures are valid. The form actually allows for electronic signatures, as long as they are original and the signer initials any changes.
All experience hours count equally. There is a belief that any hours worked can be counted toward the total. In fact, certain hours, like direct clinical counseling and supervision, have specific minimum requirements that must be met.
It’s not important to be accurate. Some individuals underestimate the significance of providing accurate information. Falsifying or omitting details can lead to serious consequences, including denial of the application.
Submitting the form is the final step. Many think that once they submit this form, their application is complete. However, it is just one part of the overall application process for licensure.

Understanding these misconceptions can help applicants navigate the process more effectively and ensure they meet all requirements.

Key takeaways

Completing the Clinical Social Experience Verification form is a crucial step in the licensure process for aspiring clinical social workers. Here are some key takeaways to keep in mind:

One form per supervisor: Each supervisor must complete a separate form. This ensures that all experiences are accurately documented and verified.
Accuracy is essential: Double-check that all information is correct before signing. Any mistakes could lead to delays or complications in your application.
Signature requirements: An original or electronic signature is necessary. If any changes are made, the signer should initial them to confirm accuracy.
Minimum experience hours: Ensure that you meet the minimum requirements for supervised weeks and hours. For example, a minimum of 3,000 total hours of experience is needed, including specific hours for direct clinical work.
Verification is mandatory: All information provided on the form is subject to verification. Providing false information can result in serious consequences, including application denial.

By keeping these points in mind, you can navigate the process with greater confidence and clarity. Remember, this form is not just a requirement; it is a reflection of your professional journey and commitment to providing quality care.