***FOR OFFICE USE ONLY***
***FOR OFFICE USE ONLY***
Application Approved:
Social Worker Checklist
License Number:
Endorsement
Examination
App. & Fee
Date:__________ Check______
Birth Certificate/Legal Entry
Photo
Transcript
Exam Results from ASWB
Lic. Verification from other States
2 Professional Reference Forms
Supervised Practice Forms (LICSW)
Issue Date:
Approved for ASWB
Signature of Board Administrator
Board Member Signatures
ID#:
Receipt #:
Rhode Island
Board of Social Work Examiners
Room 104
3 Capitol Hill
Providence, RI 02908-5097
Instructions and Application For
License As A
Licensed Clinical Social Worker
(LCSW)
Licensed Independent Clinical
Social Worker (LICSW)
Endorsement
Examination
Applicant - Print Name (First/MI/Last)
Phone: (401) 222-2828
TTY/TDD: (800) 745-5555
Fax: (401) 222-1272
Revised 07/09/2013 jcp
GENERAL INFORMATION
Enclosures
The following materials and information should be enclosed within this application packet:
Application Process Overview........................................................................................................3
Instructions for Completing Application..........................................................................................4
Application Materials
Application........................................................................................................................5-8
Application Checklist...........................................................................................................9
Professional Reference Form(s)..................................................................................10-11
Endorsement Information Form/Interstate Verification Form - Other State License(s)....12
Supervised Practice Forms (LICSW ONLY).....................................................................13
Licensure Requirements
•
Completed, notarized application.
•
Fee of $70.00 for either LCSW or LICSW.
•
Recent passport type photograph.
•
Birth Certificate (original or a copy notarized as being a true copy of the original), or if born
outside the United States, proof of citizenship or lawful alien status, (original or a copy notarized as
being a true copy of the original).
•
Official Advanced Degree Transcripts from an accredited School of Social Work.
•
Association of Social Work Boards (ASWB) examination results. (NOTE: Successful completion of
the ASWB examination IS required to obtain a license to practice social work in the state of Rhode
Island. If you are applying for approval to take the examination, then you are not required
to submit the examination results until AFTER you have taken the exam.)
•
2 Professional Reference Forms (pages 10 & 11). Presented in sealed envelope(s).
•
Supervised Practice Form(s) (page 13) (LICSW ONLY).
Endorsement
•
In addition to the above listed requirements, ALL applicants who hold or have held a Social Worker
license in any state (“Endorsement candidates”) must provide a completed Interstate Verification
Form (page 12) from each of those states.
The “Interstate Verification Form - Other State License(s)” (page 12) is provided for this purpose.
The Verfification Form from the State of original licensure must include test scores obtained on
the appropriate level of the ASWB examination (or test scores may be sent directly from ASWB). If
test scores are provided, you do not need to contact the ASWB to request the test scores. In
addition to test scores, if the Supervised Practice Prerequisite is provided by the Endorsement
State(s) (Refer to Rules & Regulations below), then you are not required to submit the Supervised
Practice Forms.
Rules and Regulations/Laws
•
To obtain the Rules and Regulations for your profession visit the A-Z list on the Topics & Programs page at the
following web site. From the list click on the letter for your profession.
http://www.health.ri.gov/atoz/
Title 5, Chapter 39.1, entitled: License Procedure for Social Workers can be downloaded at the following
website:
http://www.rilin.state.ri.us/statutes/title5/5-39.1/index.htm
Rhode Island Board of Social Work Examiners - Page 2
APPLICATION PROCESS OVERVIEW
The licensure process in the State of Rhode Island is conducted by the Rhode Island Department of Health
(HEALTH), Office of Health Professionals Regulation, and the Rhode Island Board of Social Work Examiners
(Board).
Application Process
In addition to the application, you must submit additional information directly to the Board. All items listed on the
“checklist” (page 9) must be submitted for an application to be considered complete. All applications are considered valid for 1 year from the day they are received at HEALTH. If you do not complete the application process
within 1 year, a new application must be submitted. If you are approved to take the examination, the examination
approval process does not expire within one year.
Professional Reference Forms (Pages 10 & 11) must be presented in sealed envelopes, either by mail directly
from the reference, or submitted by the applicant in an envelope sealed with the reference’s signature. Supervised Practice Form (page 13 - LICSW ONLY) must be presented in a sealed envelope, either by mail directy from
the supervisor(s), or submitted by the applicant in an envelope sealed with the supervisor’s signature across the
back flap.
All material must be received 30 days prior to a scheduled Board Meeting in order to be considered for endorsement of licensure from another jurisdiction or to be reviewed for approval to sit for the ASWB Examination.
For more information on the ASWB Examination, or for a copy of the ASWB Candidate Handbook, please
visit:
http://www.aswb.org/
http://www.aswb.org/handbook_04.pdf
Please allow a minimum of 4-6 weeks for the entire licensure process to be completed. If you have malpractice
criminal or disciplinary history, in Rhode Island or another state, it can take an additional 2 or 3 months for all
pertinent documentation to be received, and a decision to be made regarding issuance of your license.
Licenses will be issued within 7-10 working days following approval of the license. Wallet-sized license cards are
mailed within 3 weeks from the date of issuance, and are mailed to the address furnished in the application. You
are responsible for notifying the Board office, in writing, if your address changes in the interim. Visit the following
website to obtain a change of address form.
http://www.health.ri.gov/forms/changeofaddress/professions.pdf
To obtain your license number prior to receiving your license card, please refer to the HEALTH Licensee
Lookup web site:
https://healthri.mylicense.com/Verification/
HEALTH will not, for any reason, accelerate the processing of one applicant at the expense of others. Once
completed, the application will be reviewed, and you will be contacted in writing.
Please continue to review the remaining portions of this application packet for instructions and other materials
necessary to complete the application. If you have any questions about this application process, or would like to
check on the status of your application, please contact the board staff at (401) 222-2828.
Rhode Island Board of Social Work Examiners - Page 3
INSTRUCTIONS FOR COMPLETING THE LICENSE APPLICATION
Read the following instructions and those throughout the application packet carefully before completing the application. Only
complete applications with the appropriate fee will be accepted. Failure to submit all required information and appropriate documentation may result in processing delays.
General Instructions
1. Make a copy of the application and forms before you begin in case you make a mistake.
2. Type your information or print in blue or black ball-point pen. HEALTH staff will not make assumptions about illegible
information.
3. Provide a response to each section or question; otherwise mark “N/A” for Not Applicable.
4. We suggest that you make a copy of your completed application before submitting it to HEALTH.
5. It is your responsibility to check on the status of your application.
Completing your Application
1. Complete the application (pages 5-8). You must respond to all components of the application as instructed. If you
attach separate pages in continuation of the application, such pages MUST clearly indicate the section for which such
information is being reported.
2. Make check or money order (in U.S. funds only) for the application fee of $70.00 payable to Rhode Island General
Treasurer and staple it to the upper left-hand corner of the first (Top) page of the application. This application fee is
NON-REFUNDABLE .
3. For those born in US: An original or notarized copy of birth certificate. For those born outside US: An original or
notarized copy of citizenship or lawful alien status.
4. Affix a recent 2 X 2 photo of yourself in the space provided (page 8).
5. A completed official transcript sent directly from the accredited school of Social Work to the Board of Social Work
Examiners. No student copies will be accepted.
6. Examination scores, sent directly from the ASWB (Telephone 1-888-579-3926) to the Board of Social Work
Examiners (see address below).
7. (Endorsement Candidates): Please send the license verification form on page 12 to all states in which applicant
holds or has held a license. Be sure to sign and complete the identifying information on the form. HEALTH must
receive these verifications directly from the licensing authority in each state.
8. Mail the application and documentation to:
Rhode Island Department of Health
Board of Social Work Examiners, Room 104
3 Capitol Hill
Providence, RI 02908-5097
Rhode Island Board of Social Work Examiners - Page 4
State of Rhode Island and Providence Plantations
Board of Social Work Examiners
Application for License as a Licensed Clinical Social Worker or Licensed Independent Clinical Social Worker
Refer to the Application Instructions when completing these forms. Type or block print only. Do not use felt-tip pens.
1. Name(s)
This is the name that
will be printed on your
License/Permit/
Certificate and
reported to those who
inquire about your
License/ Permit/
Certificate. Do not use
nicknames, etc.
Title (i.e., Mr., Mrs., Ms., etc.)
First Name
Middle Name
Surname, (Last Name)
NOTE:
It is your responsibility to notify the
Department of Health
Board of any name
changes.
Suffix (i.e., Jr., Sr., II, III)
Maiden Name, if applicable
Name(s) under which originally licensed in another state, if different from above (First, Middle, Last).
2. Social Security
Number
3. Gender
Male
Female
4. Date of Birth
1
19 9
Month
5. Home
Address
It is your responsibility
to notify the board of all
address changes.
No professional
licensee’s address
(residence or business/
employment) will be
posted on the
Department’s Web site.
“Pursuant to Title 5, Chapter 76, of the Rhode Island General Laws,
as amended, I attest that I have filed all applicable tax returns and
paid all taxes owed to the State of Rhode Island, and I understand
that my Social Security Number (SSN) will be transmitted to the
Divison of Taxation to verify that no taxes are owed to the State.”
U.S. Social Security Number
Day
Year
1st Line Address (Apartment/Suite/Room Number, etc.)
2nd Line Address (Number and Street)
City
State
Country, If
Postal Code, If NOT U.S.
Home Phone
Zip Code
Home Fax
Email Address (Format for email address is Username@domain e.g. applicant@isp.com)
6. Business
Address
(ONLY if it is
RELATED to
your license.)
Name of Business/Work Location
1st Line Address (Department/Suite/Room Number, etc.)
Second Line Address (Number and Street)
It is your responsibility
to notify the board of all
address changes.
This address will
appear on the
Department of
Health web site.
City
State
Country, If NOT U.S.
Postal Code, If NOT U.S.
Business Phone
Extension
Zip Code
Business Fax
Rhode Island Board of Social Work Examiners - Page 5
Applicant: Print your complete last name >
7. Preferred
Mailing
Address
Please check ONE
Please use my Home Address as my preferred mailing address
Please use my Business Address as my preferred mailing address
NOTE: The preferred mailing address that you indicate is the address that will be released for all requests for that
information.
8. Qualifying
Education
Please list the name
and information about
the school that you
attended that
qualifies you for
this license.
Type of School (University, College, Technical School, etc.)
Name of School
Date Graduated
Degree Received:
Month
Is School Accredited by the Council of S.W. Education?
9. Other State
License(s)
Please answer the
question and list
state(s), if applicable
10. Licensure
List all states or
countries in which
you are now, or
ever have been
licensed to practice
your profession*.
Master’s Degree in Social Work
Year
Yes
No
Doctorate in Social Work
Yes
Have you ever held, or do you currently hold, a license in another state?
No
If the answer to this question is “yes”, enter all other state licenses in Question 10 (below):
State/Country:
License Type:
Level/Name of Examination Taken:
Active
Inactive
Clinical
Intermediate/Masters
Active
Inactive
Clinical
Intermediate/Masters
Active
Inactive
Clinical
Intermediate/Masters
Active
Inactive
Clinical
Intermediate/Masters
Active
Inactive
Clinical
Intermediate/Masters
Active
Inactive
Clinical
Intermediate/Masters
Active
Inactive
Clinical
Intermediate/Masters
Active
Inactive
Clinical
Intermediate/Masters
Active
Inactive
Clinical
Intermediate/Masters
IMPORTANT
You must also
indicate the Type
and Level of
Licensure in each of
the states that you
are licensed.
(*You must also request a License Verification (page 12) from all states that are listed above)
Rhode Island Board of Social Work Examiners - Page 6
Applicant: Print your complete last name >
11. Criminal
Convictions
Respond to the
question at the top
of the section, then
list any criminal
conviction(s) in the
space provided.
Have you ever been convicted of a violation, plead Nolo Contendere, or entered
a plea bargain to any federal, state or local statute, regulation, or ordinance or
are any formal charges pending?
Yes
No
Abbreviation of State and Conviction1 (e.g. CA - Illegal Possession of a Controlled Substance):
Month
Year
If necessary, you
may continue on a
separate 8½ x 11
sheet of paper.
12. Disciplinary
Questions
1. Has any Health Professional license, certificate, registration, or permit you
hold or have held, been disciplined or are any formal charges pending?
Yes
No
2. Have you ever been denied a license, certificate, registration or permit in any
state?
Yes
No
Check either Yes or
No for each
question.
Note: If you answer “Yes” to any question, you are required to furnish complete details, including date, place, reason
and disposition of the matter. You may use the space below or, if needed, on a separate sheet of paper.
Rhode Island Board of Social Work Examiners - Page 7
Applicant: Print your complete last name >
13. Affidavit of
Applicant
Complete this section
and sign in the
presence of a notary
public.
Make sure that you
and the notary public
have completed all
components
accurately and
completely.
I, ____________________________________, being first duly sworn, depose and say that I am the
person referred to in the foregoing application and supporting documents.
I have read carefully the questions in the foregoing application and have answered them completely, without
reservations of any kind, and I declare under penalty of perjury that my answers and all statements made by
me herein are true and correct. Should I furnish any false information in this application, I hereby agree that
such act shall constitute cause for denial, suspension or revocation of my license to practice as a Licensed
Clinical Social Worker/Licensed Independent Clinical Social Worker in the State of Rhode Island.
I understand that this is a continuing application and that I have an affirmative duty to inform the Rhode
Island Board of Social Work Examiners of any change in the answers to these questions after this application and this affidavit is signed.
_____________________________________
_________________________________
Signature of Applicant
Date of Signature (MM/DD/YY)
The foregoing instrument was acknowledged before me this _____________ day of
___________________, 20_______, by ___________________________________,
who is personally known to me or has produced ____________________________
as documentation and did / did not take an oath.
_________________________________ _________________________________
Name of Notary (Print, Type or Stamp)
Signature of Notary
________________________
__________________________
Notary No/Commission No.
Commission Expiration Date (MM/DD/YY)
Notary Seal
14. Recent
Photograph
Securely tape or
glue in this square a
current 2" x 2"
photograph of
yourself (alone).
Photographs must be
recent, passport type
photo, clear, front
view, full face
without a hat or dark
glasses.
Affix Photo Here
Full length photos will
not be accepted.
Write your name on the back of the photograph, and provide the date that the photograph was taken.
Date of Photograph
Rhode Island Board of Social Work Examiners - Page 8
APPLICATION CHECKLIST
Please review the following checklist to ensure that all the components of the application process have been satisfied. Some
items may not apply.
Board Application
I have read and understand the “Instructions for Completing the Application”.
I have completed the application as instructed (pages 5-8).
I have attached the cover page of the application.
I have completed Section 13, “Affidavit of Applicant”, and had the form notarized by a notary public.
I have attached a photograph to Section 14, “Recent Photograph” as instructed. I have verified that it meets the
photograph requirements as stated in the application.
I have attached a birth certificate (original or a copy notarized as being a true copy of the original), or if born
outside the United States, proof of citizenship or lawful alien status, (original or a copy notarized as being a true
copy of the original), and understand that submitted documents will not be returned.
I have a check or money order (preferred), made payable (in U.S. funds only) to the:
“Rhode Island General Treasurer” in the amount of $70.00 and attached it to the upper
left-hand corner of the cover page (top page) of the application.
I have arranged my Application materials in the following order.
1.
Fee (attached as instructed).
2.
Board Application (including cover page) and pages 5-8.
3.
Supporting documentation as required. [Note: Pages containing additional information in continuation of the
Board application] MUST indicate the section for which the information is being reported.]
I have mailed the above application materials directly to the Rhode Island Board of Social Work Examiners.
I have reviewed the Rules and Regulations pertaining to the Licensing of Clinical Social Workers and Independent
Clinical Social Workers.
Required Forms
I have completed and mailed the following forms as instructed.
1.
Two (2) Professional Reference Forms
2.
Endorsement Form/Interstate Verification Form(s) - Other State License(s) (Endorsement Candidates
Only).
3.
Supervised Practice Form(s) (LICSW ONLY)
Other Documents
I have requested an official school transcript and my examination scores from the ASWB as instructed.
Rhode Island Board of Social Work Examiners - Page 9
Substitute forms are not acceptable, 2 Professional Reference Forms are required per application, copy this form as needed.
Rhode Island Board of Social Work Examiners
Room 104, 3 Capitol Hill
Providence, RI 02908-5097
(401) 222-2828
PROFESSIONAL REFERENCE FORM - (NOTE: 2 Forms Required per Application)
I am applying for a license to practice as a Licensed Clinical Social Worker/Licensed Independent Clinical Social Worker in the State of Rhode Island. The
Rhode Island Board of Social Work Examiners requires that the following form be completed by “2 Professional References”. The purpose is to provide
the Rhode Island Board of Social Work Examiners with all information of any kind which the professional reference may, at his or her absolute discretion,
deem relevant to my qualifications as an applicant. By signing this form, I hereby release and discharge the professional reference (below) from all
claims arising out of the provision of such information
Print/Type Full Name
Signature
Date
Previous Names Used
Social Security Number
19
Date of Birth
THIS SECTION TO BE COMPLETED BY THE PROFESSIONAL REFERENCE*
*Special Instructions to the person providing the reference: Insert your completed reference in an envelope and seal, signing your name
across the seal. Return to the Applicant who has been instructed to include your sealed reference in his/her application packet, or return directly to
the Board at the above address. The Board assumes that you, in recommending this candidate, will be willing to interpret or to substantiate to the
Board your recommendation, should the Board desire to contact you at a later date.
Name of Professional Reference:
Relation to Applicant (e.g. Supervisor, teacher, etc):
Length of Tme applicant known by Professional Reference
(From Month & Year to Month and Year)
Questions:
1. What is the extent of knowledge by professional reference of applicant’s professional and ethical behavior
Limited
Moderate
Thorough
2. What is the amount of time spent by the applicant in social work; if part-time, indicate hours/weeks or percentages based on a 40 hour week:
3. What is the title of Applicant’s position and the name of the organization? ______________________________________________________
__________________________________________________________________________________________________________
4. Please provide a short description of the Applicant’s duties and responsibilities:
5. What is the area of the applicant’s specialties?:
6. Please provide the extent and degree of supervison exercised by the applicant in his/her position:
7. Do you certify that the applicant is an individual of Good Moral Character?
Quality and Extent of Endorsement :
Without Reservation
______________________________________________
Yes
No (If No, Please Explain):
Some Reservation (explain)
___________________
Signature
Date
_____________________________________ _____________________________
Type or Print Name
Name and Address of Organization
No Recommendation (explain)
Title
Are you a registered, licensed or
certified Social Worker?
Yes
No
If Yes, Please Indicate State and
Registration/Certification License
Number: State ____________
License Number ____________
Rhode Island Board of Social Work Examiners - Page 10
Substitute forms are not acceptable, 2 Professional Reference Forms are required per application, copy this form as needed.
Rhode Island Board of Social Work Examiners
Room 104, 3 Capitol Hill
Providence, RI 02908-5097
(401) 222-2828
PROFESSIONAL REFERENCE FORM - (NOTE: 2 Forms Required per Application)
I am applying for a license to practice as a Licensed Clinical Social Worker/Licensed Independent Clinical Social Worker in the State of Rhode Island. The
Rhode Island Board of Social Work Examiners requires that the following form be completed by “2 Professional References”. The purpose is to provide
the Rhode Island Board of Social Work Examiners with all information of any kind which the professional reference may, at his or her absolute discretion,
deem relevant to my qualifications as an applicant. By signing this form, I hereby release and discharge the professional reference (below) from all
claims arising out of the provision of such information
Print/Type Full Name
Signature
Date
Previous Names Used
Social Security Number
19
Date of Birth
THIS SECTION TO BE COMPLETED BY THE PROFESSIONAL REFERENCE*
*Special Instructions to the person providing the reference: Insert your completed reference in an envelope and seal, signing your name
across the seal. Return to the Applicant who has been instructed to include your sealed reference in his/her application packet, or return directly to
the Board at the above address. The Board assumes that you, in recommending this candidate, will be willing to interpret or to substantiate to the
Board your recommendation, should the Board desire to contact you at a later date.
Name of Professional Reference:
Relation to Applicant (e.g. Supervisor, teacher, etc):
Length of Tme applicant known by Professional Reference
(From Month & Year to Month and Year)
Questions:
1. What is the extent of knowledge by professional reference of applicant’s professional and ethical behavior
Limited
Moderate
Thorough
2. What is the amount of time spent by the applicant in social work; if part-time, indicate hours/weeks or percentages based on a 40 hour week:
3. What is the title of Applicant’s position and the name of the organization? ______________________________________________________
__________________________________________________________________________________________________________
4. Please provide a short description of the Applicant’s duties and responsibilities:
5. What is the area of the applicant’s specialties?:
6. Please provide the extent and degree of supervison exercised by the applicant in his/her position:
7. Do you certify that the applicant is an individual of Good Moral Character?
Quality and Extent of Endorsement :
Without Reservation
______________________________________________
Yes
No (If No, Please Explain):
Some Reservation (explain)
___________________
Signature
Date
_____________________________________ _____________________________
Type or Print Name
Name and Address of Organization
No Recommendation (explain)
Title
Are you a registered, licensed or
certified Social Worker?
Yes
No
If Yes, Please Indicate State and
Registration/Certification License
Number: State ____________
License Number ____________
Rhode Island Board of Social Work Examiners - Page 11
Substitute forms are not acceptable, One (1) form is required for each state in which you hold, or have held a license.
Copy this form as needed.
Rhode Island Board of Social Work Examiners
Room 104, 3 Capitol Hill
Providence, RI 02908-5097
(401) 222-2828
INTERSTATE VERIFICATION FORM - OTHER STATE LICENSE(S) (One form for each state)
I am applying for a license to practice as a Licensed Clinical Social Worker/Licensed Independent Clinical Social Worker in the State of Rhode Island. The
Rhode Island Board of Social Work Examiners requires that the following form be completed by the jurisdiction(s) in which I hold or have held a license.
This constitutes authority for you to release all information in your files, favorable or otherwise, directly to the Rhode Island Board of Social Work
Examiners at the above address.
Print/Type Full Name
Signature
Date
Previous Names Used
Social Security Number
19
License Number
Date of Birth
Date Issued
THIS SECTION TO BE COMPLETED BY THE SOCIAL WORK BOARD
Directions for State Board: Please complete and return this form to the address above with copies of any verification of supervision
received* after the applicant received their MSW. Please verify requirements met in your state:
MSW from CSWE Accredited School?
Yes
No
Licensed by Examination?
Yes
No
If not by examination, how was license obtained?
Endorsement ______ (State) Other _________________________________ (Explain)
Applicant has completed and passed the National Certification Exam: License Status:
Yes
No Score______ Level of Exam:___________________
Active
Inactive
Original Date Issued:
Expiration Date:
Lapsed
*Two years post-MSW supervised experience?
Yes
No
If YES, please indicate the total number of required post-MSW supervised hours:_____________
Questions:
1. Has this licensee ever been investigated by your Board?
Yes
No
2. Has this licensee incurred any disciplinary proceedings in your state, or is any action pending?
Yes
No
3. Has the applicant’s license ever been denied, surrendered, reprimanded, suspended, revoked or placed
Yes
No
Yes
No
on probation?
4. Do you know of any information that may discredit this person?
If you answer “Yes” to questions 1-4, please provide a written explanation below, and attach a copy of all supporting documentation (e.g.,
Board order, complaint, etc.).
__________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________
Certification:
______________________________________________
Signature
___________________
Date
__________________________________________________________________________
Type or Print Name
Please Affix
Board Seal Here
__________________________________________________________________________
Title
__________________________________________________________________________
Full Name of Licensing Board
Please return directly to the Board at the above address. Thank you for your prompt cooperation.
Rhode Island Board of Social Work Examiners- Page 12
Substitute forms are not acceptable, Copy this form as needed.
Rhode Island Board of Social Work Examiners
Room 104, 3 Capitol Hill
Providence, RI 02908-5097
(401) 222-2828
SECTION I - SUPERVISED PRACTICE FORM - CERTIFICATION OF EXPERIENCE
The individual named below is applying for certification as a Licensed Independent Social Worker in the State of Rhode Island. Prior to certifying the
applicant, it is necessary to verify his/her past clinical supervision and/or clinical experience while supervised by you. The applicant has completed
Section I and is requesting that you complete Section II. By signing below, the applicant attests that the information is correct to the best of his/her
knowledge.
Print/Type Full Name
Signature
Date
Previous Names Used
Social Security Number
19
Dates of Clinical Experience under supervision
of the practitioner completing Section II.
FROM:
Date of Birth
TO:
Month
Day
Year
Month
Day
Year
Description of Applicant’s Primary Responsibilities and position:
Number of Hours
Worked per Week
Number of Direct Client
Contact Hours per Week
INSTRUCTIONS TO APPLICANT: If you have had more than one supervisor, and evidence is needed from two or more supervisors to document the
minimum level of supervised clinical experience required for Licensure, the applicant must complete Section I on each form forwarded to the individual
supervisors. It is the responsibility of the applicant to gather all forms completed by supervisors in sealed envelopes with supervisor’s signature
across the back flap (seal) and mail in one packet to the Rhode Island Board of Social Work Examiners.
EXPERIENCE REQUIREMENTS FOR LICSW: Chapter 5-39.1 of the General Laws of the State of Rhode Island establishes experience requirements
which must be met prior to application for the Independent Clinical Social Work License. These requirements became effective on July 1, 1994.
Experience is defined as three thousand (3,000) hours of post-master’s practice of clinical social work during a twenty-four (24) to seventy-two
(72) month period of time immediately preceding the date of application for LICSW. One thousand five hundred (1,500) hours must consist of
providing clinical social work services directly to clients. Clinical social work practice is defined as the professional application of social work
theories, methods, and values in the diagnosis, assessment, and treatment of cognitive, affective and behavioral disorders arising from physical,
environmental, or emotional conditions. Clinical social work services also include psychotherapy and counseling for individuals, couples, families ,
and groups; client-centered advocacy; consultation and supervision. NOTE: The experience must occur DURING A 24-72 MONTH PERIOD of time
immediately preceding the date of the application for licensure (2 YEAR MINIMUM, 6 YEAR MAXIMUM).
Supervison is defined as face-to-face contact with a licensed independent social worker (LICSW) for the purpose of apprising the supervisor of the
diagnosis, assessment, and treatment of each client; receiving oversight and guidance from the supervisor in the delivery of clinical social work
services to each client; and being evaluated by the supervisor.
1.) A minimum of two (2) hours of supervision every two (2) weeks.
2.) A minimum of one (1) hour of supervision per twenty (20) hours of direct contact with clients.
3.) One-to-one (Individual Supervision) contact with the supervisor at least seventy-five percent (75%) of the time.
4.) Supervision by an individual other than the applicant’s parents; spouse; former spouse; siblings; children; employees; or anyone sharing the
same household or any romantic, domestic or familial relationship.
SECTION II - THIS SECTION TO BE COMPLETED BY SUPERVISOR
Instructions to supervisor: Please complete Section II of this form and return to the applicant. The Rhode Island Board of Social Work
Examiners requests that the supervisor carefully review the applicant’s statements under Section I prior to responding to Items in Section II. Insert
completed form in an envelope and seal signing your name across the seal. Return to applicant. Applicant has been instructed to include your
sealed envelope in his/her application packet.
Supervisor’s Professional
Degree, Discipline and
License Information:
Agency and State in which Supervision Occurred:
Agency
State
Describe the nature of the Supervision:
Degree:
Discipline:
License Level:
License #:
Length and frequency of Supervision:
Certification:
I hereby attest the above information in Section II is correct, to the best of my knowledge.
License State:
Signature
Type or Print Name
Date
Title
Supervisor’s Address:
Please return this form to the applicant. Thank you for your cooperation.
Rhode Island Board of Social Work Examiners- Page 13
