LCSWA Name and License Number: Place of Employment: Supervisor’s Name and License Number: Case Narrative applies to Review period: mm/dd/yyyy to mm/dd/yyyy
LCSW SHORT-FORM APPLICATION (Three-Part Document) PART I: Affirmation and Signature . Note: This document to be used only by LCSW Associates who have completed all requirements for LCSW licensure:
LCSW ASSOCIATE RENEWAL INFORMATION . Continuing education (CE) for License renewal is required to maintain professional knowledge and technical competency.
CSWM, currently serving as Board Chair, and Dr. Alfred Bryant, Jr., Ph.D., LPC currently serving as Board Vice- Chair. The five new appointments fill both professional and public member positions on the Board as required by
LCSWA Name and License Number: Place of Employment: Supervisor’s Name and License Number: Case Narrative applies to Review period: mm/dd/yyyy to mm/dd/yyyy
ZIP PHONE # FAX # Christina Dauer, RD Shraddha Sharma, MD: Elizabeth Elam, RDN Brenda Thomas, PA-C: Nadeen Elhaddad, RD Amanda Thompson, FNP-C: Christopher Elkins, CPNP Jennifer Thompson, MD