Social Work Psychotherapy Privilege Form 1SWRP "Application for Licensed Clinical Social Worker Psychotherapy "r" Privilege" - New York

What Is Social Work Psychotherapy Privilege Form 1SWRP?

This is a legal form that was released by the New York State Education Department - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2017;
  • The latest edition provided by the New York State Education Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Social Work Psychotherapy Privilege Form 1SWRP by clicking the link below or browse more documents and templates provided by the New York State Education Department.

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Download Social Work Psychotherapy Privilege Form 1SWRP "Application for Licensed Clinical Social Worker Psychotherapy "r" Privilege" - New York

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This Area For Department Use Only
www.op.nysed.gov
Licensed Clinical Social Worker Psychotherapy "R" Privilege
Form 1SWPR
The University of the State of New York
Application for Licensed Clinical Social Worker
The State Education Department
Office of the Professions
Psychotherapy "R" Privilege
Division of Professional Licensing Services
All applicants for the psychotherapy privilege must complete this form and submit it with the $100 fee for the
psychotherapy privilege directly to the Office of the Professions at the address at the end of this form. You must
sign and date the attestation on this form in the presence of a Notary Public.
1.
73
$100 PS
2.
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
3.
Birth Date
Month
Day
Year
4.
Print Name
Last
First
Middle
Licensee business address, phone and email address are public information. Failure to
indicate business or home on this form for each item will deem it public information.
5.
Mailing Address
Home or
Business
(You must notify the Department promptly of any address or name changes)
Line 1
Line 2
Line 3
City
State
ZIP Code
Country/
Province
6.
Telephone/Email Address
Daytime Phone
Email Address (please print clearly)
Home or
Business
Home or
Business
Area Code
Phone
7.
New York State DMV ID Number
(Driver or Non-Driver ID)
(Leave this blank if you do not have a New York State DMV ID Number)
8.
New York State LCSW license number
M.S.W. degree date
mo.
day
yr.
Date LCSW license issued
Date registration ends
mo.
day
yr.
mo.
day
yr.
Licensed Clinical Social Worker Psychotherapy "R" Privilege Form 1SWPR, Page 1 of 2, Revised 8/17
This Area For Department Use Only
www.op.nysed.gov
Licensed Clinical Social Worker Psychotherapy "R" Privilege
Form 1SWPR
The University of the State of New York
Application for Licensed Clinical Social Worker
The State Education Department
Office of the Professions
Psychotherapy "R" Privilege
Division of Professional Licensing Services
All applicants for the psychotherapy privilege must complete this form and submit it with the $100 fee for the
psychotherapy privilege directly to the Office of the Professions at the address at the end of this form. You must
sign and date the attestation on this form in the presence of a Notary Public.
1.
73
$100 PS
2.
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
3.
Birth Date
Month
Day
Year
4.
Print Name
Last
First
Middle
Licensee business address, phone and email address are public information. Failure to
indicate business or home on this form for each item will deem it public information.
5.
Mailing Address
Home or
Business
(You must notify the Department promptly of any address or name changes)
Line 1
Line 2
Line 3
City
State
ZIP Code
Country/
Province
6.
Telephone/Email Address
Daytime Phone
Email Address (please print clearly)
Home or
Business
Home or
Business
Area Code
Phone
7.
New York State DMV ID Number
(Driver or Non-Driver ID)
(Leave this blank if you do not have a New York State DMV ID Number)
8.
New York State LCSW license number
M.S.W. degree date
mo.
day
yr.
Date LCSW license issued
Date registration ends
mo.
day
yr.
mo.
day
yr.
Licensed Clinical Social Worker Psychotherapy "R" Privilege Form 1SWPR, Page 1 of 2, Revised 8/17
9.
Attestation
I declare and affirm that the statements made in this application, including accompanying documents, are true, complete and correct. I
understand that any false or misleading information in, or in connection with, my application may be cause for denial of qualification and
may lead to a filing of charges of professional misconduct. This form must be signed and dated in the presence of a Notary Public.
Applicant's Signature
Date
Notary
State of
County of
On the
day of
in the year
before me, the above signed,
personally appeared
, personally known to me or proved to me on the basis
Applicant name
of satisfactory evidence to be the individual whose name is subscribed to this application and acknowledged to me that he/she executed
the application and swore that the statements made by him/her in the application and all supporting materials are true, complete, and
correct.
Notary Public's Signature
Notary Stamp
Notary ID number
Expiration Date
Plan for Experience
Before starting the experience for the "R" privilege, you must submit for review and approval by the State Board for Social Work, a Plan For
Post-LCSW Supervised Experience (Form 6SWPR) that will meet the requirements of this paragraph. The plan for supervision shall specify:
a. individual or group consultation of no less than two hours per month; or
b. enrollment in a program authorized to provide psychotherapy offered by an institution of higher education or by a psychotherapy
institute chartered by the Board of Regents
The supervisor must be a
1. licensed clinical social worker with the "R" privilege;
2. a licensed psychologist; or
3. a licensed physician who is a diplomate in psychiatry of the American Board of Psychiatry and Neurology, Inc. or had equivalent
training and experience as determined by the Department.
The experience must be completed in an authorized setting, as defined in the Education Law and Part 74.5 of the Commissioner's Regulations.
You can access more information about qualified supervisors in the SWPR Appendix A.
A Plan For Post-LCSW Supervised Experience (Form 6SWPR) must be submitted by the supervisor for review and approval by the State
Board. Your Form 6SWPR will not be reviewed unless you have already submitted a Form 1SWPR and $100 fee.
Mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany,
NY 12201, U.S.A.. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.
Licensed Clinical Social Worker Psychotherapy "R" Privilege Form 1SWPR, Page 2 of 2, Revised 8/17
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