ࡱ> / bjbj  bhbhv!E4PPPh ,PB( #$ &rAtAtAtAtAtAtA$-DFA;+  ;+;+A4=B222;+vrA2;+rA22j?h@gn+?^ASB0B?Go,G @G@''2x(t(O'''AA_1'''B;+;+;+;+G'''''''''X : Kentucky Board of Social Work 125 Holmes Street, Suite 310 Frankfort KY 40601 502-564-2350  HYPERLINK "http://bsw.ky.gov" http://bsw.ky.gov SUPERVISION EXPERIENCE DOCUMENTATION FORM FOR LICENSED CLINICAL SOCIAL WORKER INSTRUCTIONS This form is to be used with Microsoft Word. Press the TAB key to skip to the next field. Once you have completed the form, you must print the form, and apply your handwritten signature. Applications submitted without the appropriate signatures will be returned. The completed form must be submitted to the Kentucky Board of Social Work. Once you have completed all supervision documentation forms, you need to complete your LCSW application on line at the board website. KENTUCKY BOARD OF SOCIAL WORK 125 HOLMES STREET, SUITE 310 FRANKFORT, KY 40601  HYPERLINK "http://bsw.ky.gov/" http://bsw.ky.gov/ (502) 564-2350 SUPERVISED EXPERIENCE DOCUMENTATION FORM FOR LICENSED CLINICAL SOCIAL WORKER (To Be Completed by Applicant Only) (PART I) QUALIFYING EXPERIENCE UNDER SUPERVISION  FORMCHECKBOX Non Exempt Agency ExperienceA certified social worker whos supervision experience was obtained in Kentucky under a Board approved supervision contract with a qualified licensed clinical social worker consistent with the requirements of 201 KAR 23:070 (copy attached)  FORMCHECKBOX Exempt Agency Experience A certified social worker whose experience was obtained while employed with an agency exempt pursuant to KRS 335.010 (3), (4), and (5). Attach a job description for employment setting where supervision occurred. (The job description must be signed by the Executive Director or Human Resources Director.)  FORMCHECKBOX Out of State Experience A clinical social worker licensed in another state must submit the following documentation verifying that the supervision experience received in the licensing state meets the requirements of 201 KAR 23:070. Supervision Experience Documentation Form (Part I, II, and III) An official job description on agency letterhead signed by the Executive Director, Human Resources Director, or Agency Supervisor for employment setting where supervision occurred. Official verification of the supervisors credentials.  SUPERVISED EXPERIENCE DOCUMENTATION FORM FOR LICENSED CLINICAL SOCIAL WORKER (To Be Completed by Supervisor Only) (PART II) NAME OF APPLICANT: FORMTEXT       The above named individual has applied for licensure as a Clinical Social Worker in the Commonwealth of Kentucky. One of the requirements is two (2) years of supervised social work practice as a Certified Social Worker. Recognizing that you are legally and ethically responsible for the activities of the applicant during the period of time you were the supervisor, please use the utmost care in being specific in the details you provide on the following form. Your candid and complete evaluation of this applicant is critical for licensure and, ultimately, the protection of the consumer. SUPERVISOR CREDENTIALS 1.Name of Supervisor: FORMTEXT      Degree: FORMTEXT       2.Title at time applicant was supervised: FORMTEXT       3.Date first approved as supervisor for this applicant: FORMTEXT       4.Place(s) & Date(s) of original and current licensure: FORMTEXT        FORMTEXT      License #(s) FORMTEXT       5.Your highest graduate degree: FORMTEXT      Major: FORMTEXT       6.Title of school granting degree: FORMTEXT      Graduation Date: FORMTEXT       7.Number of years working as a professional Licensed Clinical Social Worker: FORMTEXT       8.Date of completion of supervision training (If applicable): FORMTEXT      (Please attach copy of most recent supervisory training certificate)- Applicable to in state licensees only. 9.Are you the Supervisor of Record? FORMCHECKBOX  Yes  FORMCHECKBOX  No 10.Are you an additional supervisor? FORMCHECKBOX  Yes  FORMCHECKBOX  No 11.Do you have a relationship with this applicant outside of the supervisory relationship?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, Explain: FORMTEXT        FORMTEXT        FORMTEXT       *********************************************************************************************************** IF YOU ARE A SUPERVISOR FROM OUT OF STATE PLEASE ATTACH A RESUME AND OFFICIAL VERIFICATION OF LICENSURE. *********************************************************************************************************** Signature FORMTEXT      Title FORMTEXT      Current Address FORMTEXT      Email Address  FORMTEXT      Telephone Number FORMTEXT      Date SUPERVISED EXPERIENCE DOCUMENTATION FORM FOR LICENSED CLINICAL SOCIAL WORKER (To Be Completed by Supervisor Only) (PART III) NAME OF APPLICANT: FORMTEXT       NAME OF SUPERVISOR: FORMTEXT       1.Name and Address of agency where supervised experience was gained: FORMTEXT        FORMTEXT        FORMTEXT       2.The applicant s title / position during the period of clinical experience: FORMTEXT       Please list only the supervision you provided for this applicant. You may not verify or account for supervision provided by another supervisor. 3.Please note: Kentucky social work law and regulations require that you complete a minimum of 150 hours, which shall include individual supervision of not less than two (2) hours during every two (2) weeks of clinical social work practice and no more than 100 hours of group supervision in groups of six (6) or less over a two (2) year (full-time) or three (3) year (part-time) basis.How many hours per week of each of the following did the applicant accumulate under your supervision?  FORMTEXT :;O\]|}~ԭufuWWIIhLxCJOJQJ^JaJhLx5CJOJQJ^JaJhC95CJOJQJ^JaJhLx5CJOJQJ^JaJhLx5OJQJ^JhLxCJOJQJ^JaJhLx0JCJOJQJ^JaJ)jhLxCJOJQJU^JaJ#jhLxCJOJQJU^JaJhLxCJOJQJ^JaJhsgCJOJQJ^JaJhLx5CJOJQJ^JaJ;O\! N G $ & Fa$$a$ ^`gdC9$a$ ! N V o   ( - E G ! 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FORMTEXT       Group (You may be asked for verification)  1.)Total number of individual, face to face supervision hours accumulated under your supervision: FORMTEXT      2.)Total number of group supervision hours accumulated under your supervision: FORMTEXT      3.)Total number of supervision hours accumulated under your supervision (Total of 1 and 2): FORMTEXT       4.Beginning and ending dates of supervision you provided (dates must match the approval letter received from this board:From (month/day/year) FORMTEXT      to (month day year) FORMTEXT       5.In which of the following services did the applicant demonstrate competency that can be qualified and in your professional opinion, is qualified to perform independently: General Services ProvidedServices OfferedSpecialty Services**CheckCheckCheckTherapy FORMCHECKBOX Child Evaluations FORMCHECKBOX Custody Evaluation FORMCHECKBOX Evaluation FORMCHECKBOX Child Treatment FORMCHECKBOX School Social Work FORMCHECKBOX Consultation FORMCHECKBOX Marital / Conjoint Therapy FORMCHECKBOX Other:  FORMTEXT       FORMCHECKBOX Play Therapy FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Geriatrics FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Competency Evaluations FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Eating Disorders / Family FORMCHECKBOX Family Therapy FORMCHECKBOX Group Therapy FORMCHECKBOX Substance Abuse / Addiction FORMCHECKBOX Other:  FORMTEXT       FORMCHECKBOX  **Must have had substantial training and experience to be prepared for independent practice. 6.Did you provide this applicant with a written or oral evaluation of his or her work regular basis? Please discuss the nature of the supervisory relationship.  FORMCHECKBOX  Yes  FORMCHECKBOX  No. FORMTEXT        FORMTEXT       7.Based upon your overall experience with this applicant, do you personally attest to sufficient competence of professional judgment requisite to independent, unsupervised practice? (This is not an optional question. Please be specific.)  FORMTEXT       FORMTEXT       8.Do you have any information that would aid the Kentucky Board of Social Work in evaluating this application to pursue independent practice? (This is not an optional question. Please be specific.)  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