Free 50325.FH11 - Indiana

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APPLICATION FOR LICENSURE AS A CLINICAL SOCIAL WORKER (LCSW)
State Form 50325 (R2 / 2-06) Approved by State Board of Accounts, 2006

SOCIAL WORKER, MARRIAGE AND FAMILY THERAPIST AND MENTAL HEALTH COUNSELOR BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room 072 Indianapolis, Indiana 46204 Telephone: (317) 234-2064 E-mail: [email protected]

* Your Social Security number is being requested by this state agency in accordance with I.C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.

FOR OFFICE USE ONLY

APPLICATION/PERMIT FEE: DATE FEE PAID: RECEIPT NUMBER: LICENSE NUMBER ISSUED: PERMIT NUMBER ISSUED: DATE LICENSE ISSUED:
ALL INFORMATION ON THIS FORM MUST BE TYPED OR CLEARLY PRINTED.
What date (month, day, year) did you begin taking classes to complete your MSW degree? I am applying for a temporary permit:

Attach Two Passport Quality Photographs Here (See Instructions)

Attach Two Passport Quality Photographs Here (See Instructions)

Yes
I have previously made application for this profession in the State of Indiana under the name of:

No

APPLICANT INFORMATION
Name (last, first, middle, maiden or previous) Current address (number and street or rural route) City Permanent address (IF DIFFERENT FROM ADDRESS ABOVE) City Work telephone number (include area code) State ZIP code State ZIP code

(

)

Home telephone number (include area code)

(

)

E-mail address Date of birth (month, day, year) Social Security number * Place of birth (city, state)

Please check all that apply: I am applying for licensure by examination. I am applying for licensure by exemption from the examination (ENDORSEMENT). I am currently licensed / certified in another state. Type of licensure / certification Issued by I successfully passed the ASWB examination. Date State Level of Examination Page 1

UNDERGRADUATE AND GRADUATE EDUCATION
Name of academic institution: Location (city and state) Name of academic institution: Location (city and state) Name of academic institution: Location (city and state) Name of academic institution: Location (city and state) Name of academic institution: Location (city and state) Name of academic institution: Location (city and state) Department Dates attended (month, year to month, year) Department Dates attended (month, year to month, year) Department Dates attended (month, year to month, year) Department Dates attended (month, year to month, year) Department Dates attended (month, year to month, year) Department Dates attended (month, year to month, year) Program title Degree earned Program title Degree earned Program title Degree earned Program title Degree earned Program title Degree earned Program title Degree earned

EMPLOYMENT HISTORY FOR THE PAST FIVE (5) YEARS

Please list all places of professional employment, including self-employment. You may add an additional sheet listing employment if more space is needed.
Name of employer Location (city and state) Duties or responsibilities Name of employer Location (city and state) Duties or responsibilities Name of employer Location (city and state) Duties or responsibilities Name of employer Location (city and state) Duties or responsibilities Name of employer Location (city and state) Duties or responsibilities Position or title Dates employed (month, year to month, year) Name of supervisor Average hours per week Position or title Dates employed (month, year to month, year) Name of supervisor Average hours per week Position or title Dates employed (month, year to month, year) Name of supervisor Average hours per week Position or title Dates employed (month, year to month, year) Name of supervisor Average hours per week Position or title Dates employed (month, year to month, year) Name of supervisor Average hours per week

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OTHER STATE LICENSURE / CERTIFICATION

Do you now hold, or have you ever held, a license / certification / registration / permit to practice any regulated health profession by a state licensing board? Yes No (If yes, list all states below, including Indiana, in which you have held a license / certification / registration / permit to practice any state regulated health occupation.)
TYPE OF LICENSE / CERTIFICATE / REGISTRATION / PERMIT 1. 2. 3. 4. 5. STATE LICENSE NUMBER DATE ISSUED STATUS

If your answer is "Yes" to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date and disposition. If malpractice, provide name(s) of plaintiff(s). Letters from attorneys or insurance companies are not accepted in lieu of your statement. Falsification of any of the following is grounds for permanent revocation of a license or permit issued pursuant to this application. 1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held? 2. Have you ever been denied a license, certificate, registration or permit to practice medicine, osteopathic medicine or any regulated health occupation in any state (including Indiana) or country? 3. Are you now being, or have you ever been treated for drug or alcohol abuse? 4. Have you ever been convicted of, pled guilty or nolo contendre to: A. A violation of any Federal, State or local law relating to the use, manufacturing, distribution or dispensing of controlled substances or drug addiction? B. Any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines) 5. Have you ever been denied staff membership or privileges in any hospital or health care facility or had such membership or privileges revoked, suspended or subjected to any restrictions, probation or other type of discipline or limitations? 6. Have you ever been admonished, censured, reprimanded or requested to withdraw, resign or retire from any hospital or health care facility in which you have trained, held staff membership or privileges or acted as a consultant? 7. Have you ever had a malpractice judgment against you or settled any malpractice action? Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No

APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date signed (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, corporation, association, organization or institution to release to the Professional Licensing Agency, or Indiana Social Worker, Marriage and Family Therapist and Mental Health Counselor Board, any files, documents, records or other information pertaining to the undersigned requested by the Agency, or the Board, or any of their authorized representatives in connection with processing my application for licensure. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency, or the Indiana Social Worker, Marriage and Family Therapist and Mental Health Counselor Board, to disclose to the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions any information which is material to my application, and I hereby specifically release the Agency, and the Board from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION I hereby swear or affirm, that I have read the above statements and agree to same.
Signature of applicant Date signed (month, day, year)

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FORM I - VERIFICATION OF SUPERVISION FOR LSW / LCSW LICENSURE APPLICANTS
State Form 50324 (R2 / 2-06)

ALL INFORMATION ON THIS FORM MUST BE TYPED OR CLEARLY PRINTED.

APPLICANT: Complete the top section of this form, then forward it to your supervisor. You are authorized to photocopy this form as necessary.
Name of applicant (last, first, middle) Address (number and street or rural route, city, state, and ZIP code) Social Security number * Name of supervisor Supervisor title Date of birth (month, day, year) Telephone number (daytime) Maiden or given surname

(
Name of business / institution Address (number and street, or rural route, city, state, and ZIP code)

)

I hereby authorize, ____________________________________________ to furnish to the Professional Licensing Agency with the information below.
(Supervisors Name) Signature of applicant Date (month, day, year)

SUPERVISOR: Complete the remainder of this form, have the form notarized and return it directly to the Professional Licensing Agency, 402 West Washington Street, Room 072, Indianapolis, IN 46204. SUPERVISOR INFORMATION
Name of supervisor (last, first, middle) State license / certificate number / type of license / certificate Name of business / institution License / certificate issued by Business telephone number (include area code)

(
Business address (number and street or rural route, city, state, and ZIP code) Number of years of experience in Social Work or Clinical Social Work

)

E-mail address

APPLICANT EMPLOYMENT INFORMATION
Applicants job title during the time of your supervision Date supervision began (month, day, year) Number of hours applicant worked per week Number of face to face client contact hours per week Brief description of how supervision was conducted: Applicants employer during the time of your supervision Date supervision ended (month, day, year) Number of hours you supervised applicant per week face to face

I was present at the applicants place of work. The applicants work requirement was at a different site but: (1) There was an equivalent supervisor on site. (2) The applicant was not engaged in independent private practice.

True True True

False False False

The above indicated supervision was performed by me pursuant to my order, control, and full professional and legal responsibility as a supervisor. I do hereby declare that the information contained herein is true and correct.

SEAL OF NOTARY PUBLIC

Signature: Title: Date (month, day, year):

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FORM II - VERIFICATION OF EMPLOYMENT / EXPERIENCE FOR LSW / LCSW LICENSURE APPLICANTS
State Form 50324 (R2 / 2-06)

ALL INFORMATION ON THIS FORM MUST BE TYPED OR CLEARLY PRINTED. APPLICANT: Complete the top section of this form, then forward it to your employer. You are authorized to photocopy this form as necessary.
Name of applicant (last, first, middle) Address (number and street or rural route, city, state, and ZIP code) Social Security number * Name of business / institution Date of birth (month, day, year) Address (number and street, or rural route, city, state, and ZIP code) Date your MSW degree was granted: (month, day, year) Telephone number (daytime) Maiden or given surname

(
Date you began taking classes to complete your MSW degree: (month, day, year)

)

I hereby authorize, ____________________________________________ to furnish to the Professional Licensing Agency with the information below.
(Employers Name) Signature of applicant Date (month, day, year)

EMPLOYER: Complete the remainder of this form, have the form notarized and return it directly to the Professional Licensing Agency, 402 West Washington Street, Room 072, Indianapolis, IN 46204. EMPLOYER INFORMATION
Name of employer Name of business / institution where employed Business address (number and street or rural route, city, state,and ZIP code) Business / Institute telephone number Date employment began (month, day, year) Date employment ended (month, day, year) (if currently employed, please indicate) E-mail address

(

)

Position held Brief description of the responsibilities that the applicant had while in your employment:

Number of hours applicant worked per week

The applicant pursuant to my order, control, and full professional and legal responsibility as an employer has performed the above-indicated experience. I do hereby declare that the information contained herein is true and correct. Signature:

SEAL OF NOTARY PUBLIC

Title and Printed Name: Date (month, day, year):

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FORM III - MSW CLINICAL COURSEWORK
State Form 50324 (R2 / 2-06)

To be complete by all applicants for LCSW licensure who began taking classes to complete a MSW degree after July 1, 1997
Please list the course titles in the areas indicated below, of the graduate courses, exactly as they appear on your transcript, that in your opinion, meet the following requirements. If the title of the course you are wishing to apply towards these requirements does not clearly reflect these content areas, you should also submit additional supporting documentation, such as course descriptions from your college or universitys catalog. A total of twenty four (24) semester hours or thirty seven (37) quarter hours of graduate coursework is required and must include at least three (3) credit hours in each of the following seven (7) content areas. A course may only be credited once in identifying courses taken in the seven (7) content areas.

Psychopathology
Educational Institution Course # Course Title Semester Hours Quarter Hours

Clinical Practice with Diverse Populations
Educational Institution Course # Course Title Semester Hours Quarter Hours

Clinical Theory and Practice
Educational Institution Course # Course Title Semester Hours Quarter Hours

Family Practice
Educational Institution Course # Course Title Semester Hours Quarter Hours

Group Practice
Educational Institution Course # Course Title Semester Hours Quarter Hours

Human Behavior in the Social Environment
Educational Institution Course # Course Title Semester Hours Quarter Hours

Practice Evaluation (Research)
Educational Institution Course # Course Title Semester Hours Quarter Hours

I, the undersigned applicant for Clinical Social Workers licensure, do hereby certify that I have also completed the following A supervised field placement that was a part of my advanced concentration in direct practice during which I provided clinical services directly to clients.
Signature of applicant Date (month, day, year)

Printed name of applicant

Social Security number *

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