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A B C 9. Was one additional hour of face-to-face individual or two hours of face-to-face group supervision given for every week in which more than 10 hours of face-to-face psychotherapy was performed Yes 37A-201 Rev. 04/2015 SUPERVISOR INFORMATION Supervisor s Name License Type License Number Date First Licensed 1. STATE OF CALIFORNIA - BUSINESS CONSUMER SERVICES AND HOUSING AGENCY Governor Edmund G* Brown Jr. Board of Behavioral Sciences 1625 North Market Blvd. Suite S200 Sacramento CA 95834 Telephone 916 574-7830 TTY 800 326-2297 www. bbs. ca*gov CLINICAL SOCIAL WORKER EXPERIENCE VERIFICATION Your supervisor must complete this form as follows o Use a separate form for each supervisor and employer o Provide an original signature in ink and have the signer initial any changes o Make sure this form is complete and correct prior to signing All information on this form is subject to verification APPLICANT NAME ASW APPLICANT S EMPLOYER INFORMATION Applicant s Employer s Name Address Business Telephone Number and Street City State Zip Code 1. Did this setting lawfully and regularly provide clinical social work mental health counseling or psychotherapy Yes No scope of practice Yes EXPERIENCE INFORMATION Dates of experience From to mm/dd/yyyy 1. Total supervised weeks minimum 104 2. Total hours in individual supervision minimum 52 4. Average hours worked per week max 40 individual or group psychotherapy / counseling minimum 2 000 A. 6. Of the above hours how many were gained performing face-to-face individual or group B. 8. Total hours of experience minimum 3 200 C. If a physician were you certified in Psychiatry by the American Board of Psychiatry and Neurology during the entire period of supervision If YES provide certificate number 2. Were you employed by the supervisee s employer Yes agreement between you and the supervisee s employer. If NO attach a copy of the letter of 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* Signature of Supervisor Date. STATE OF CALIFORNIA - BUSINESS CONSUMER SERVICES AND HOUSING AGENCY Governor Edmund G* Brown Jr. Board of Behavioral Sciences 1625 North Market Blvd. Suite S200 Sacramento CA 95834 Telephone 916 574-7830 TTY 800 326-2297 www. bbs. ca*gov CLINICAL SOCIAL WORKER EXPERIENCE VERIFICATION Your supervisor must complete this form as follows o Use a separate form for each supervisor and employer o Provide an original signature in ink and have the signer initial any changes o Make sure this form is complete and correct prior to signing All information on this form is subject to verification APPLICANT NAME ASW APPLICANT S EMPLOYER INFORMATION Applicant s Employer s Name Address Business Telephone Number and Street City State Zip Code 1. Suite S200 Sacramento CA 95834 Telephone 916 574-7830 TTY 800 326-2297 www. bbs. ca*gov CLINICAL SOCIAL WORKER EXPERIENCE VERIFICATION Your supervisor must complete this form as follows o Use a separate form for each supervisor and employer o Provide an original signature in ink and have the signer initial any changes o Make sure this form is complete and correct prior to signing All information on this form is subject to verification APPLICANT NAME ASW APPLICANT S EMPLOYER INFORMATION Applicant s Employer s Name Address Business Telephone Number and Street City State Zip Code 1. Did this setting lawfully and regularly provide clinical social work mental health counseling or psychotherapy Yes No scope of practice Yes EXPERIENCE INFORMATION Dates of experience From to mm/dd/yyyy 1.