Current New York State Licensure Status:
None
LMSW
LCSW
Limited Permit (please indicate which): LMSW   LCSW

Work Setting (If you work in multiple settings, indicate only one per comment form and answer all questions as they relate to this one setting. If you are experiencing licensure issues in multiple settings, submit a separate form for each setting):

Employed in an Agency
If yes to “Employed in Agency”:

Does your agency have a Certificate of Operation that includes social work services, psychotherapy, or other similar language?

Yes                  No

*What is this?*

Are you working in an agency position that is exempt until 2010?

Yes                  No

*What is this?*

Individually Owned Private Practice

Partner, Group Private Practice

Employee, Group Private Practice (not a partner or part owner)

Other (please specify):

City in which you practice?

Are you currently providing Licensed Clinical Social Work services (i.e., diagnosis, psychotherapy, and assessment-based treatment plans per NYS social work licensure law)?
Yes                  No

What type of clinical supervision are you currently receiving?

Internal supervision (receiving supervision from professional within your agency or practice)

Third-party supervision (supervised by professional unaffiliated with agency or practice)

Not receiving clinical supervision

What are your Clinical Supervisor’s credentials:
Licensed Clinical Social Worker
Licensed Psychologist
Psychiatrist
Other (please specify)

What social work credential are you seeking?
LMSW
LCSW
R#
Not seeking any credential

Do you have an application pending for the above?
Yes                  No

Has your application for the above been denied, or have there been other difficulties with the application? Please provide a detailed description of the reason(s) cited for the denial:

Are you experiencing other difficulties related to social work licensure? Please describe in detail: