Licensed Clinical Social Worker by Completing Provisional

APPLICATION INSTRUCTIONS
Licensed Clinical Social Worker by Completing Provisional (LCSW)
Be aware that you must continue to work under administrative supervision and clinical supervision by your Designated
Clinical Supervisor until the license for independent clinical practice is issued by the Board.
Specific requirements are detailed in the Rules and Regulations. Please review the requirements prior to submitting an
application.
GENERAL INFORMATION
• Application files will be presented to the Application Review Committee (Committee) for consideration when all
required documentation has been received.
• The Committee will not review your qualifications without receipt of a formal application and fee.
• The application fee for licensure by completing the provisional is $200.00. Make checks payable to the “State of
Wyoming”. Do not send cash. All fees are non-refundable regardless of the outcome.
• All documents offered in support of the application must be submitted directly to the Committee from the source, not
forwarded through you.
Required Documents:
• Complete application
• Appropriate application fee
• The provisional license identification card
• A revised disclosure statement
Additional Documents:
• Verification and Evaluation of Supervised Experience
• Official Exam Score Report
DOCUMENTS
INSTRUCTIONS
Application
• The check boxes for Discipline and Method are completed for you.
• Type or print all information clearly.
• Items #1-4 need no specific instruction.
• Items #5 and 6 Current Employer- It is very important that you provide your current employer, and not your
prospective employer. If you are currently unemployed, please leave this area blank.
• Item #7 Preferred Mailing Address- If you do not indicate a preference our records will default to your home
address.
• Item #8 E-mail Address- Provide an e-mail address that you check regularly. We will notify you via e-mail when
your application form is received. If there are any issues or questions concerning your application, these will be
communicated to you through e-mail.
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• Item #9 Work History- List all employment since the issuance of your provisional license. Start with your most
recent employment/experience and work backward in time. Account for all gaps in time such as periods of
unemployment.
• Items #10-19- Provide a written explanation for each of your “Yes” answers. Make sure that your name appears on
additional documents. Include documentation such as certified copies of court records, state disciplinary action
documents, letters of sanction from professional associations, etc.
• Read the Warning, Agreement and Affidavit. Remember, you are stating that you have read, and agree to abide
by, the rules and regulations. The rules are available on the Board’s web page at
http://plboards.state.wy.us/mentalhealth. Read them. Sign and date the application. Please sign in blue ink. Mail
the original application, appropriate fee and proof of legal presence to the Board.
Provisional License Identification Card
• Include the pocket sized provisional license identification card with your application.
• If you are unable to return the card, attach a brief explanation of the reason.
Revised Disclosure Statement
• Include a copy of the revised Professional Disclosure Statement that you will use once you are granted a license by
the Board.
• The particular criteria for the disclosure statement can be found in the Rules and Regulations, Chapter 15 Section
1(xxvii), although you should have been providing a disclosure statement to your clients since the issue date of your
provisional license.
Verification and Evaluation of Supervised Experience
• This form must be submitted by every Designated Clinical Supervisor you have had since the provisional license
was granted, regardless of the length of time you were under their supervision.
• This form must be send directly to the Board from the Supervisor. The Board will not accept this information from
you or through your hands in any way.
• This information is be kept confidential by the Board, although you may be informed of the number of hours
reported.
• Only clinical experience that was completed under the supervision of an approved designated clinical supervisor
may be applied towards the experience and supervision requirements for licensure.
Official Exam Score Report
• The Board will accept the Association of Social Work Boards (ASWB) examination at the Advanced Generalist or
Clinical Level.
• Contact ASWB and request that an official examination score report be send directly to the Board. The Board will
not accept this information from you or through your hands in any way.
PROCEDURE
You will receive an e-mail acknowledging that your application form and fee have been received. You may inquire about
your application status by e-mailing to WyoMHPLB@wyo.gov. Please limit your inquiries to no more than twice per week.
When all required supportive documents have been received, the Application Review Committee will evaluate your
application. You will be notified of the outcome.
Inquiries regarding these application procedures and application status may be directed to WyoMHPLB@wyo.gov.
Mental Health Professions Licensing Board
2001 Capitol Ave, Room 104
Cheyenne, WY 82002
Web Site: http://plboards.state.wy.us/mentalhealth
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MENTAL HEALTH PROFESSIONS LICENSING BOARD
2001 Capitol Ave, Room 104
Cheyenne WY 82002
http://plboards.state.wy.us/mentalhealth
WyoMHPLB@wyo.gov
APPLICATION
Specific requirements are detailed in the Rules and Regulations which are available on our web page. Review the requirements prior to submitting your application.
Please type or print legibly, preferably in blue ink. The Board will only accept originally signed applications. Before mailing be sure to include payment of the
application fee. Make checks payable to the “State of Wyoming”. Do not send cash. All fees are non-refundable regardless of the outcome.
Incomplete applications WILL NOT be reviewed.
Select from these check boxes if you are applying for certification at the bachelor’s degree level or equivalent, or with specialty training for the CAPA.
ADDICTIONS PRACTITIONER
ADDICTIONS PRACTITIONER ASSISTANT
DISCIPLINE:
(One only)
SOCIAL WORKER
METHOD:
(One only)
EXAMINATION
RECIPROCAL
Select from these check boxes if you are applying for licensure at the master’s degree level.
ADDICTIONS THERAPIST
PROVISIONAL
DISCIPLINE: CLINICAL SOCIAL WORKER
METHOD: COMPLETING PROVISIONAL
(One only) MARRIAGE AND FAMILY THERAPIST (One only) EXAMINATION
PROFESSIONAL COUNSELOR
RECIPROCAL
$300.00 fee
$300.00 fee
$150.00 fee
$200.00 fee
$350.00 fee
$350.00 fee
1. NAME:
2.
3.
SOCIAL
SECURITY:
LEGAL
PRESENCE: U.S. OTHER
Last First Middle Initial Previous Names Used
DATE OF
BIRTH:
(U.S. Code Title 8, Chapter 14, Section 1621 requires proof of legal presence in the United States. Attach
acceptable documentation from enclosed List A and B.)
TELEPHONE NUMBER(S):
4.
HOME
ADDRESS:
Street Address
( )
Home
5.
CURRENT
EMPLOYER:
( )
City State Zip Cell
Business Name
TELEPHONE NUMBER(S):
6.
BUSINESS
ADDRESS:
Street Address
( )
Phone
( )
City State Zip Fax
7. PREFERRED MAILING ADDRESS: HOME BUSINESS
8. E-MAIL ADDRESS:
Please provide an e-mail address that you check regularly. If there are any questions or issues regarding your
application, the Board staff will communicate with you at this address.
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9. EXPERIENCE: List all employment since the issuance of your provisional license. Begin with today and work back in time. Note
any interruptions in time, such as periods of unemployment. Refer to the application instructions for additional direction.
From: To: Supervisor:
Month/Year
Month/Year
Organization:
Address:
Brief Description of Work:
From: To: Supervisor:
Month/Year
Month/Year
Organization:
Address:
Brief Description of Work:
From: To: Supervisor:
Month/Year
Month/Year
Organization:
Address:
Brief Description of Work:
From: To: Supervisor:
Month/Year
Month/Year
Organization:
Address:
Brief Description of Work:
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HISTORY
10. Have you ever, or are you now, providing any of the services regulated by W.S. 33-38-101 et seq. in the
State of Wyoming, without meeting the requirement for licensure or certification, or without meeting an
exemption provided in W.S. 33-38-103?
Yes
No
11. Has any state rejected or denied your application for certification or licensure in any profession? Yes No
12. Has any state revoked, suspended, refused to renew, or otherwise restricted your certificate or license in
any profession?
13. Have you ever voluntarily surrendered your certificate or license in any profession in order to avoid
disciplinary action by a regulatory agency in any state?
Yes
Yes
No
No
14. Have you ever been sanctioned by a professional association? Yes No
15. Have you been convicted of a misdemeanor involving moral turpitude, including pleas of nolo contendere
or no contest?
Yes
No
16. Have you been convicted of a felony in any profession, including pleas of nolo contendere or no contest? Yes No
17. Are you addicted to, or do you habitually use alcohol, any controlled substance, or other drugs having
similar effects?
Yes
No
18. Have you ever been judged incompetent by a court of law? Yes No
19. Have you ever violated and been convicted of a charge under the Wyoming Controlled Substances Act? Yes No
Attach a written explanation if you answered "YES" to any of questions 10 through 19 above. Include documentation related to your
“YES” answer(s), including, but not limited to, certified copies of court records, letters of sanction, state board disciplinary action
documents, etc.
WARNING
Making a false statement or giving a false answer to any question on this form is a felony punishable by imprisonment for not more than
two (2) years, a fine of not more than two thousand dollars ($2,000.00), or both. (W.S. § 6-5-303.)
AGREEMENT
In signing this application, I do hereby state that I have read, understand, and agree to abide by the rules and regulations promulgated
by the Mental Health Professions Licensing Board, and W.S. § 33-38-101 through 113. I also agree to adhere to the codes of ethics
applicable to my profession and this application.
AFFIDAVIT
The undersigned, being duly sworn, deposes and says that he or she is the person making the foregoing statements and that they are
made in good faith and are true in every respect.
SIGNATURE OF APPLICANT
DATE
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MENTAL HEALTH PROFESSIONS LICENSING BOARD
2001 Capitol Ave, Room 104
Cheyenne WY 82002
http://plboards.state.wy.us/mentalhealth
WyoMHPLB@wyo.gov
VERIFICATION AND EVALUATION OF SUPERVISED EXPERIENCE
SUPERVISOR
IT IS VERY IMPORTANT THAT YOU READ AND COMPLY WITH THESE DIRECTIONS.
Your name has been submitted by the applicant as someone who has supervised their professional clinical experience. The Board, as well as
the applicant, would appreciate your providing the information requested and returning this form directly to the Board at the above address.
Please do not give the completed form to the applicant to be submitted to the Board. Please do not ask the applicant to complete any
information on this form. The Board will not accept this information from the applicant or through the applicant’s hands in any way. This
information will be kept confidential by the Board, although the applicant may be informed of the number of hours reported. The information
provided will not be reviewed unless all areas of this form are completed. Incomplete forms will not be accepted and will be returned to the
supervisor. Failure to return this form will affect the applicant’s ability to become independently licensed.
APPLICANT’S
NAME:
Last First Middle Initial
EXPERIENCE
WAS EARNED
AT:
SUPERVISOR’S
NAME:
Business Name
Street Address
TELEPHONE NUMBER(S):
( )
Phone
( )
City State Zip Fax
Last First Middle Initial
TELEPHONE NUMBER(S):
SUPERVISOR’S
CURRENT
ADDRESS:
Street Address
( )
Home
E-MAIL
ADDRESS:
( )
City State Zip Cell
Please provide an e-mail address that you check regularly. If there are any questions or issues regarding your responses, we will
communicate with you at this address.
REGISTRATION: List each license YOU held during the time you supervised this applicant. In order to be considered a qualified clinical
supervisor, you must have been licensed for at least (2) years with at least four (4) years of experience PRIOR to supervising the applicant. Report
the date that your license was originally issued, and not the date that it was last renewed.
LICENSE TITLE
LICENSE
NUMBER
STATE
ORIGINAL
ISSUE DATE
EXPIRATION
DATE
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CLINICAL EXPERIENCE
Report the amount of clinical experience gained by the applicant. This includes all hours worked. Direct client contact hours must also be
reported. Deduct for holidays, vacation, and other time off.
FOR EXPERIENCE COMPLETED IN WYOMING- The “From” date cannot be prior to the date the Provisional Supervision Agreement
was approved by the Board.
FOR EXPERIENCE COMPLETED OUT-OF-STATE- The “From” date cannot be less than two (2) years after the issue date of the
supervisor’s clinical license at the independent practice level.
From: To: at an average of hours per week for a total of hours,
MM/YYYY
MM/YYYY
which included
hours of direct client contact.
For example:
From: 1/2000 To: 12/2000 at an average of 40 hours per week for a total of 1840 hours,
MM/YYYY MM/YYYY (Time deducted for vacations and holidays.)
which included 650 hours of direct client contact.
DESCRIBE THE PROFESSIONAL DUTIES which the applicant performed under your supervision: (For Addictions Therapy and
Marriage and Family Therapy applicants, indicate the percentage of time spent with addiction clients or couples and families.)
CLINICAL SUPERVISION
Report the amount of face-to-face supervision that you provide to the applicant. Group supervision MAY NOT be included in the report.
TRIADIC supervision is an arrangement where the designated qualified clinical supervisor conducts clinical supervision with two (2) supervisees
simultaneously.
During the time frame noted above:
Individual face-to-face supervision was provided at an average of hours per week for a total of hours.
Triadic face-to-face supervision was provided at an average of hours per week for a total of hours.
For example:
TOTAL FACE-TO-FACE CLINICAL SUPERVISION:
Individual face-to-face supervision was provided at an average of .5 hours per week for a total of 25 hours.
Triadic face-to-face supervision was provided at an average of 1 hours per week for a total of 50 hours.
TOTAL FACE-TO-FACE CLINICAL SUPERVISION: 75
DESCRIBE THE CLINICAL SUPERVISION PROCESS:
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EVALUATE THE APPLICANT ON THE FOLLOWING:
UNABLE
TO
EVALUATE
POOR
AVERAGE
ABOVE
AVERAGE SUPERIOR
Skill Level
Ability to establish and maintain good professional relations.
Possession of emotional maturity & stability required for satisfactory work with clients and
patients.
Understanding of and adherence to approved standards of professional and ethical conduct.
Personal character: honesty, integrity and general conduct.
Reputation among colleagues as a professional.
Capacity for professional growth and development.
I would rate the applicant's overall performance under my supervision as:
I would rate the applicant's competence to engage in independent clinical practice as:
PROVIDE ANY ADDITIONAL INFORMATION REGARDING THE APPLICANT WHICH YOU MAY CONSIDER
RELEVANT:
I recommend that the applicant be considered for licensing without reservation.
I recommend that the applicant be considered for licensing with reservation as outlined above.
I do not recommend that the applicant be considered for licensing as outlined above.
I hereby certify that the information provided in this document is fair and accurate in every respect.
SIGNATURE
DATE
The signed Verification and Evaluation of Supervised Experience may be e-mailed to WyoMHPLB@wyo.gov,
or faxed to (307) 777-3508,
or mailed to the address provided on this form.
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