Licensed Clinical Social Worker Psychotherapy R Privilege Form 6SWPR The University of the State of New York THE STATE EDUCATION DEPARTMENT Office of the Professions Division of Professional Licensing Services www. op.nysed.gov Plan for Post-LCSW Supervised Experience Applicant Instructions Complete Section I. In item 3 enter your name exactly as it appears on your Application for Licensed Clinical Social Worker Psychotherapy R Privilege Form 1SW.
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How to fill out the NY 6SWPR online
This guide provides clear, step-by-step instructions on how to fill out the New York 6SWPR form online. Whether you are a seasoned professional or new to the process, this comprehensive overview will help you navigate the requirements efficiently.
Follow the steps to complete the NY 6SWPR form.
- Click the ‘Get Form’ button to access the NY 6SWPR form and open it in your preferred editor.
- In Section I, provide your applicant information. Enter your name as it is listed on your Application for Licensed Clinical Social Worker Psychotherapy 'R' Privilege (Form 1SWPR) in item 3. Ensure to sign and date item 7.
- Fill in your date of birth and Social Security Number, leaving the Social Security Number field blank if you do not possess one.
- Complete your mailing address, including all necessary fields like line 1, city, state, and zip code. It's important to notify the Department of any changes to your name or address.
- Provide details regarding your proposed clinical supervisor and the setting in which you will be gaining your experience. This includes the supervisor's name, license number, and the date the license was issued.
- In the attestation section, affirm the accuracy of the information you have provided by signing and dating the form. Make sure the signature matches your official identification.
- Once Section I is completed, send the entire form along with a copy of Appendix A to your supervisor for their review and completion of Section II.
- The supervisor must fill out Section II, provide their notarized signature, and return the entire form directly to the Office of the Professions.
- After completing and verifying all sections of the form, you can save the changes, download it for your records, print it out, or share it with relevant parties as needed.
Complete your NY 6SWPR form online today for a seamless filing experience.
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