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Lcsw Form 4B. In item 3, enter your name exactly as it appears on your application for licensure (form 1). Web be sure to sign and date item 10.
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Applicants must hast supervised experience approved in order to meet licensing eligibility. Web licensed clinical social worker form 4b certification of experience for licensed clinical social worker instructions for completing section ii: Web before you accept a position practicing clinical social work. Request your supervisor to submit verification of your supervised hours in diagnosis and psychotherapy on form 4b. Web licensed clinical social worker. Be sure to sign the affidavit and return the entire form directly to the office of the professions at the address at the end of this form. Nysed office of the professions. You must also complete a separate form 4b for each supervised experience you list on the applicant experience record (form 4). Licensed clinical social worker form 4, page 2 of 2, revised 8/17. In item 3, enter your name exactly as it appears on your application for licensure (form 1).
Licensed master social worker (lmsw) licensed clinical social worker (lcsw) In item 3, enter your name exactly as it appears on your application for licensure (form 1). Assigned number (from form 4): Request your supervisor to submit verification of your supervised hours in diagnosis and psychotherapy on form 4b. Web complete and submit this form, making sure to sign and date item 10; Web before you accept a position practicing clinical social work. Be sure to complete a separate form 4b for each supervised experience listed on your applicant experience record (form 4). Nysed office of the professions. Licensed clinical social worker form 4, page 2 of 2, revised 8/17. Licensed master social worker (lmsw) licensed clinical social worker (lcsw) Web find form 2 here: