California Clinical Social Worker In-State Experience Verification Form
This form is for applicants seeking to verify their in-state clinical social worker experience. It must be filled out by the applicant's California supervisor and submitted with the Application for Licensure. The form collects details about the supervisor, applicant, and the supervised experience.
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How do I fill this out?
Begin by filling out your personal information and that of your supervisor. Provide detailed information about your supervised experience, ensuring accuracy and completeness. Follow the instructions carefully to avoid any issues with your application.
How to fill out the California Clinical Social Worker In-State Experience Verification Form?
1
Fill out your personal details and associate number.
2
Provide your supervisor's information including license details.
3
Detail your employment information and if you were paid or volunteered.
4
List the supervised experience details such as weeks, hours, and activities.
5
Have your supervisor sign and date the form.
Who needs the California Clinical Social Worker In-State Experience Verification Form?
1
Licensed Clinical Social Workers who need to verify their in-state experience.
2
Applicants who are submitting their Application for Licensure.
3
Supervisors who are required to validate an applicant's supervised experience.
4
Individuals needing to document their clinical psychosocial diagnosis hours.
5
People who are applying for licensure and must provide proof of supervised work.
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1
Open the PDF in PrintFriendly's editor.
2
Enter your personal and supervisor's information into the respective fields.
3
Complete the sections detailing your supervised experience.
4
Review the form for any errors or missing information.
5
Save and download the edited PDF.
What are the instructions for submitting this form?
Submit the completed form with your Application for Licensure. Ensure all sections are filled accurately, and include your written agreement if applicable. Mail to Board of Behavioral Sciences, 1625 North Market Blvd., Suite S200, Sacramento, CA 95834 or email to BBSLicensing@dca.ca.gov. Ensure you have included W-2 forms or letters verifying volunteer status as needed.
What are the important dates for this form in 2024 and 2025?
The revised form DCA BBS 37A-201 should be used from May 2024 onwards.
What is the purpose of this form?
The purpose of this form is to enable Licensed Clinical Social Workers or applicants to provide verified details of their in-state supervised experience in California. It collects critical information about the supervision and work performed by the applicant. This ensures that the Board of Behavioral Sciences has all the necessary documentation for the Application for Licensure.
Tell me about this form and its components and fields line-by-line.
- 1. Applicant Information: Includes the applicant's name, associate number, and dates of experience.
- 2. Supervisor Information: Details about the supervisor including name, email, license type, and number.
- 3. Employment Information: Information about the applicant's employer, address, and pay status.
- 4. Experience Information: Details on the supervised weeks, hours, and nature of the clinical work experience.
- 5. Supervisor Signature: The supervisor's signature and date to verify the form's contents.
What happens if I fail to submit this form?
Failing to submit this form may result in denial of the licensure application. It is imperative to ensure all required information is provided accurately.
- Application Denial: Your application for licensure may be denied due to missing or incorrect information.
- Disciplinary Action: Providing false information can lead to disciplinary action against the supervisor.
How do I know when to use this form?
- 1. Licensure Application: Submitting alongside your Application for Licensure.
- 2. Supervision Validation: Providing details about the supervision received.
- 3. Employment Verification: Confirming employment details and nature of the work.
- 4. Experience Documentation: Documenting the number of hours and types of activities performed.
- 5. Formal Verification: Supervisor's signature to formally verify the experience details.
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