Transcription of Licensed Clinical Social Worker 4B
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Licensed Clinical Social Worker 4B
The University of the State of New York The State Education Department Office of the Professions Division of Professional Licensing Services Clinical Social Worker Form 4B Certification of Experience for Licensed Clinical Social Worker 1. Complete Section I. In item 3, enter your name exactly as it appears on your Application for Licensure (Form 1). Be sure to sign and date item 8. Use the psychotherapy log to document your hours of practice and supervision. This log must be completed by you and your supervisor. All pages of the log must be retained by the supervisor, in the event the State Board requests clarification.
I am licensed and currently registered to practice as a (check all that apply) Licensed Clinical Social Worker
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