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Education Department  \u003Cbr>Office of the Professions  \u003Cbr>Division of Professional Licensing Services  \u003Cbr>www.op.nysed.gov   | Licensed Clinical Social Worker Form 4B  \u003Cbr>Certification of Experience for Licensed Clinical Social Worker   |\n| --- | --- |\n| Applicant Instructions  \u003Cbr>Assigned Number (from Form 4):   |  |\n| 1.Complete Section l.In item 3,enter your name exactly as it appears on your Application for Licensure(Form 1).Be sure to sign and date  \u003Cbr>item 8.Use the psychotherapy log to document your hours of practice and supervision.This log must be completed by you and your  \u003Cbr>supervisor.All pages of the log must be retained by the supervisor,in the event the State Board requests clarification.  \u003Cbr>2.Send the entire form along with a copy of Appendix A to your supervisor (if your supervisor is unavailable,you must provide the  \u003Cbr>supervisor's qualifications and your experience may be verified by a licensed colleague)and ask him/her to complete Section Il and  \u003Cbr>forward the entire form directly to the Office of the Professions at the address at the end of the form.This form will not be accepted if  \u003Cbr>submitted by the applicant.Note:If the experience being certified on this form was completed outside New York State,you must  \u003Cbr>also have a Form 4Q submitted by this supervisor.   |  |\n| Section I:Applicant Information  \u003Cbr>1.Last 4 Digits of Social Security Number  \u003Cbr>2.  Birth Date Month  \u003Cbr>Year  \u003Cbr>Day  \u003Cbr>(Leave this blank if you do not have a U.S.Social Security Number)  \u003Cbr>3.Print Name Last  \u003Cbr>First  \u003Cbr>5.Telephone/Email Address  \u003Cbr>Daytime Phone  \u003Cbr>Middle  \u003Cbr>Home or□Business  \u003Cbr>Licensee business address,phone and email address are public information.Failure to  \u003Cbr>indicate business or home on this form for each item will deem it public information.  \u003Cbr>Phone  \u003Cbr>Area Code  \u003Cbr>4.Mailing Address□Home or   Business  \u003Cbr>(NOTE:The address you provide will be used to update your file with the Department.  \u003Cbr>EmailAddress(please print clearly)  \u003Cbr>Any license parchment and/or registration certificate will be mailed to your address on  \u003Cbr>□  Home or□ Business  \u003Cbr>file.You must notify the Department within 30 days of any address or name change.)  \u003Cbr>Line 1  \u003Cbr>Line 2  \u003Cbr>6.New York State DMV ID Number  \u003Cbr>(Driver or Non-Driver ID)  \u003Cbr>Line 3  \u003Cbr>City  \u003Cbr>(Leave this blank if you do not have a  \u003Cbr>New York State DMV ID Number)  \u003Cbr>State  \u003Cbr>ZIP Code  \u003Cbr>Country/  \u003Cbr>Province   |  |\n| 7.Name as it appears on degree or other credentials (if different from above)   |  |\n| M.S.W.degree date  \u003Cbr>8.New York State LMSW license number  \u003Cbr>mo.day yr.  \u003Cbr>Date LMSW license issued  \u003Cbr>Date registration ends  \u003Cbr>mo.day yr.  \u003Cbr>mo.day yr.   |  |\n| 9.You must complete not less than 2,000 client contact hours of post-MSW supervised experience in diagnosis,psychotherapy and  \u003Cbr>assessment-based treatment plans over a period of at least 36 months and no more than 6 years.You must be supervised by a licensed  \u003Cbr>clinical social worker,licensed psychologist or physician who meets the requirements of section 74.6 of the Commissioner's Regulations in  \u003Cbr>an acceptable setting as defined in section 74.6  \u003Cbr>Name of clinical supervisor   |  |\n| Name of setting   |  |\n| Setting address   |  |\n| 10.I declare andafrm that the statements made in the foregoing application,including accompanying statements are true,complete and  \u003Cbr>correct I understand that any false or misleading information in,or in connection with my application may be cause for denial of licensure  \u003Cbr>and may lead to a filing of charges of professional misconduct.  \u003Cbr>Signature   |  |\n| Date   |  |\n| Licensed Clinical Social Worker Form 4B,Page 1 of 2,Rev.10/24   |  |\n\n\n| Section II:Supervisor's Certification of Supervised Experience   |  |  |\n| --- | --- | --- |\n| |Instructions to the Registrar:Read the attached Appendix A and complete all of Sectionl Be sure to sig","cbCaifKQHIYskMcn","https://ap.wps.com/l/cbCaifKQHIYskMcn","pdf",773564,"English","# Applicant Instructions\n## Section I: Applicant Information\n## Section II: Supervisor's Certification of Supervised Experience","[{\"question\":\"What is Licensed Clinical Social Worker Form 4B used for?\",\"answer\":\"Form 4B is used to certify an applicant’s supervised experience for Licensed Clinical Social Worker licensure, including the required psychotherapy log documentation and supervisor certification.\"},{\"question\":\"What information must the applicant provide in Section I?\",\"answer\":\"Section I collects the applicant’s identifying information (including Social Security details if applicable), birth date, name, phone/email, mailing address, DMV ID (if applicable), degree/credential name, and prior license details.\"},{\"question\":\"What must the supervisor complete in Section II?\",\"answer\":\"The supervisor must certify licensure status, identify the employment setting where supervision occurred (with required attachments such as authorization waivers or certificates), and complete the supervisor affidavit so the form can be submitted to the Office of the Professions.\"}]","Licensed Clinical Social Worker Form 4B - Certification of Experience for Licensed Clinical Social Worker | PDF",1789989041]