LICENSURE REQUIREMENTS FOR CLINICAL SOCIAL WORKER Effective December 12, 2013 These requirements are summarized from the Board’s Rules and Regulations. Please review Chapter 9 of the Rules at http://mentalhealth.wyo.gov for complete details.

General: Be of a majority age; and Have no felony convictions, and no misdemeanor convictions involving moral turpitude, although the Board may grant exceptions to this requirement if consistent with the public interest; and Are a legal inhabitant of the United States; and Demonstrate integrity, professionalism and character in clinical social work through three (3) professional recommendations which attest to applicants’ abilities and professional performance.

Education: Complete of a graduate degree program in social work from a Council on Social Work Education (CSWE) accredited program.

Experience/Supervision: Complete a minimum of three thousand (3,000) hours of supervised clinical training/work experience in clinical social work under the direct supervision of a designated qualified clinical supervisor. All three thousand (3,000) hours of supervised clinical training/work experience required shall be completed after the award of the master’s degree. Of the three thousand (3,000) hours required, at least one thousand two hundred (1,200) hours shall be direct client contact hours. A minimum of one hundred (100) post master’s hours of direct, verifiable, individual and/or triadic face-to-face clinical supervision with a designated qualified clinical supervisor is required. Group supervision is not acceptable towards completion of the face-to-face clinical supervision requirement. Those persons who are issued a provisional license before January 2, 2011 may also submit experience and supervision earned as part of their master’s degree practicum and internship towards meeting the experience and supervision requirement, provided the experience is clinical in nature, and the supervisor meets the criteria for a Qualified Clinical Supervisor.

Examination: The Board will accept the Association of Social Work Boards (ASWB) examination at the Advanced Generalist or Clinical Level. Other examinations may be approved by the Board on a case by case basis.

APPLICATION INSTRUCTIONS Provisional Clinical Social Worker (PCSW) Provisional licensure is a means by which an individual may continue progress towards satisfactory completion of the education, experience, supervision and examination requirements for independent clinical practice. Be aware that if you do not meet one of the exemptions provided in W.S. 33-38-103, you MAY NOT provide clinical services in Wyoming until you are issued a license 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 a provisional license is $150.00. 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 Board office from the source, not forwarded through you. DOCUMENTS

Required Documents: • Complete application • Appropriate application fee • Documentation of legal presence in the U.S. (See attached list A and B) • Official transcript(s) of your master’s degree program • Three (3) professional references Additional Documents: • Provisional License Supervision Agreement • State License/Certification Verification • Professional Disclosure Statement 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. Item #9 Registrations- Provide complete information regarding any licenses or certifications you now hold or have ever held in any profession. Item #10 Education- Make sure that you have reviewed the education criteria for licensure in Clinical Social Work. Item #11 Reference- Provide the requested information for the 3 persons who will be submitting a Professional Reference form on your behalf. These forms must be provided directly to the Board from the reference. The Board cannot accept these references from you or through your hands in any way. Item #12 Professional Credentials- Provide information regarding your professional certifications such as NASW, etc. This information may be valuable to the Committee particularly for reciprocal applicants. Item #13 Work History- Start with your most recent employment/experience and work backward in time. Account for all gaps in time such as periods of unemployment or education. Items #14-23- 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://mentalhealth.wyo.gov. 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.

Documentation of Legal Presence in the U.S. • U.S. Code Title 8, Chapter 14, Section 1621 requires that all licensing agencies collect proof of legal presence in the United States. Generally applicants find it easiest to provide a copy of a state issued birth certificate, a copy of a passport, or a copy of a social security card. • Originals will not be returned. • If you cannot provide any of these documents, please refer to the enclosed List A and B for other acceptable documents. Official Transcript • Request that the college or university listed on your application under item #10, send an official transcript of your master's degree program directly to the Board office. The school may e-mail the transcript to [email protected], fax it to (307) 777-3508, or mail it to the address provided in these instructions. • The Committee will not accept transcripts issued to you or received directly from you unless they are in a sealed envelope stamped by the registrar across the seal. • Make sure that your college or university is regionally accredited. By this we mean accredited by one of the regional or national institutional accrediting bodies recognized by the Council for Higher Education Accreditation (CHEA). You can verify your school’s accreditation online at http://www.chea.org/search/default.asp. • You can verify if your educational program was accredited by CSWE online at http://www.cswe.org. Professional Reference • You must request Professional References three (3) professionals with at least six (6) months of direct knowledge of your abilities and professional performance in social work. Do not request Professional References from the person who will be designated as your clinical supervisor for provisional license. • Professional References must be submitted on the forms provided by the Board. The reference may e-mail the form to [email protected], fax it to (307) 777-3508, or mail it to the address provided in these instructions. • Professional References must be sent directly to the Committee from the reference and not forwarded through you. • Professional References must have been written within six (6) months of your application date. • Professional References will not be accepted from natural or legal relatives.

Provisional License Supervision Agreement • Read the agreement thoroughly. • Type or clearly print your name and your supervisor’s name in the spaces provided at the top of the agreement. • Meet with your supervisor to discuss the agreement and your supervision arrangement. • Send the completed agreement to the Committee. You may submit this agreement with your application, or e-mail the agreement to [email protected], fax it to (307) 777-3508, or mail it to the address provided in these instructions. • The agreement is not required to be issued a provisional license, but it is required in order to provide clinical services once you are provisionally licensed. • Clinical practice is not permitted without an approved supervision agreement. • Experience and supervision completed without a Committee approved supervision agreement will not apply towards licensure. State License/Certification Verification • Verification may be requested if you hold or have held licensure or certification in another state in any profession. • Do not request official license verification(s) at this time. The Committee may request that you provide an official verification based on their review of your file. • If required, complete only the Applicant section of the form and send it to the state licensing board(s) listed under item #9 on your application. We recommend that you contact the licensing board before sending them the form. Most licensing boards charge a fee to verify licenses. • Do not complete this form yourself or send this form to the Committee with your application. It must be sent directly to the Committee from the state licensing board where you hold/held a license. Professional Disclosure Statement • Include a copy of the 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). PROCEDURE You will receive an e-mail acknowledging that your application form, fee, and proof of legal presence have been received. You may inquire about your application status by e-mailing to [email protected]. 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 [email protected] Mental Health Professions Licensing Board 2001 Capitol Ave, Room 104 Cheyenne, WY 82002 Web Site:

http://mentalhealth.wyo.gov

LIST A ACCEPTABLE DOCUMENTS TO ESTABLISH U.S. CITIZENSHIP A person who is a citizen of the United States as evidenced by one of the following: 1. 2. 3.

4. 5. 6. 7. 8. 9.

A copy of a birth certificate issued in or by a city, county, state, or other governmental entity within the United States or its outlying possessions. A U.S. Certificate of Birth Abroad (FS-545, DS-135) or a Report of Birth Abroad of a U.S. Citizen (FS-240). A birth certificate or passport issued from: A. Puerto Rico, on or after January 13, 1941; B. Guam, on or after April 10, 1898; C. U.S. Virgin Islands, on or after February 25, 1927; D. Northern Mariana Islands, after November 4, 1986; E. American Samoa; F. Swain’s Island; or G. District of Columbia. A U.S. passport (expired or unexpired). Certificate of Naturalization (N-550, N-57, N-578). Certificate of Citizenship (N-560, N-561, N-645). U.S. Citizen Identification Card (I-179, I-197). An individual Fee Register Receipt (Form G-711) that shows that the person has filed an application for a New Naturalization or Citizenship Paper (Form N-565). Any other documents which establish a U.S. place of birth or indicate U.S. citizenship.

LIST B ACCEPTABLE DOCUMENTS TO ESTABLISH ALIEN STATUS An alien lawfully admitted for permanent residence under the Immigration and Naturalization Act (INA) must submit supporting documentation to establish legal presence under one of the following categories: 1.

2.

3.

4. 5.

6.

7. includes:

8. 9.

An alien lawfully admitted for permanent residence under the Immigration and Naturalization Act (INA). Evidence includes: Χ INS Form I-551 (Alien Registration Receipt Card commonly known as a “green card”); or Χ Unexpired Temporary I-551 stamp in foreign passport or on INS Form I-94. An alien who is granted asylum under Section 208 of the INA. Evidence includes: Χ INS Form I-94 annotated with stamp showing grant of asylum under Section 208 of the INA; Χ INS Form I-688B (Employment Authorization Card) annotated “274a.12(a)(5)”; Χ INS Form I-766 (Employment Authorization Document) annotated “A5"; Χ Grant Letter from the Asylum Office of INS; or Χ Order of an immigration judge granting asylum. A refugee admitted to the United States under Section 207 of the INA. Evidence includes: Χ INS Form I-94 annotated with stamp showing admission under Section 207 of the INA; Χ INS Form I-688B (Employment Authorization Card) annotated “274a.12(a)(3)”; Χ INS Form I-766 (Employment Authorization Document) annotated “A3"; or Χ INS Form I-571 (Refugee Travel Document). An alien paroled into the United States for at least one year under Section 212(d)(5) of the INA. Evidence includes: Χ INS Form I-94 with stamp showing admission for at least one year under Section 212(d)(5) of the INA. An alien whose deportation is being withheld under Section 243(h) of the INA (as in effect immediately prior to September 30, 1996) or Section 241(b)(3) of such Act (as amended by Section 305(a) of Division C of Public Law 104-208). Evidence includes: Χ INS Form I-668B (Employment Authorization Card) annotated “274a.12(a)(10)”; Χ INS Form I-766 (Employment Authorization Document) annotated “A10"; or Χ Order from an immigration judge showing deportation withheld under Section 243(h) of the INA as in effect prior to April 1, 1997, or removal withheld under Section 241(b)(3) of the INA. An alien who is granted conditional entry under Section 203(a)(7) of the INA as in effect prior to April 1, 1980. Evidence includes: Χ INS Form I-94 with stamp showing admission under Section 203(a)(7) of the INA; Χ INS Form I-688B (Employment Authorization Card) annotated “274a.12(a)(3)”; or Χ INS Form I-766 (Employment Authorization Document) annotated “A3". An alien who is a Cuban or Haitian entrant (as defined in Section 501(e) of the Refugee Education Assistance Act of 1980). Evidence Χ INS Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”) with the code CU6, CU7, or CH6; Χ Unexpired temporary I-551 stamp in foreign passport or on INS Form I-94 with code CU6 or CU7; or Χ INS Form I-94 with stamp showing parole as “Cuban/Haitian Entrant” under Section 212(d)(5) of the INA. An alien paroled into the United States for less than one year under Section 212(d)(5) of the INA. Evidence includes: Χ INS Form I-94 showing this status. An alien who has been declared a battered alien. Evidence includes: Χ INS petition and supporting documentation. The preceding lists (A and B) contain the most common documents, which can be used to establish U.S. Citizenship or legal alien

status.

MENTAL HEALTH PROFESSIONS LICENSING BOARD 2001 Capitol Ave, Room 104 Cheyenne WY 82002 http://mentalhealth.wyo.gov [email protected]

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:  Proof of legal presence as required by item #3 of the application. Applicants generally find it easiest to provide a copy of their social security card, or a copy of their passport, or a copy of their government issued birth certificate. Originals will not be returned. If you are unable to provide a copy of any of these documents please refer to the enclosed list A and B. A copy of your driver’s license IS NOT an acceptable form of identification for proof of legal presence.  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. DISCIPLINE: (One only)

 ADDICTIONS PRACTITIONER  ADDICTIONS PRACTITIONER ASSISTANT  SOCIAL WORKER

METHOD: (One only)

 EXAMINATION  RECIPROCAL

$300.00 fee $300.00 fee

Select from these check boxes if you are applying for licensure at the master’s degree level. DISCIPLINE: (One only)

1.

 ADDICTIONS THERAPIST  CLINICAL SOCIAL WORKER  MARRIAGE AND FAMILY THERAPIST  PROFESSIONAL COUNSELOR

3.

METHOD: (One only)

$150.00 fee $200.00 fee $350.00 fee $350.00 fee

NAME: Last

2.

 PROVISIONAL  COMPLETING PROVISIONAL  EXAMINATION  RECIPROCAL

SOCIAL SECURITY: LEGAL PRESENCE:

First

Middle Initial

Previous Names Used

DATE OF BIRTH:



U.S.



OTHER

(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:

Home

( City

5.

)

Street Address

State

)

Zip

Cell

CURRENT EMPLOYER: Business Name

TELEPHONE NUMBER(S):

6.

(

BUSINESS ADDRESS:

)

Street Address

Phone

( City

State

7.

PREFERRED MAILING ADDRESS:

8.

E-MAIL ADDRESS:



HOME

Zip



) Fax

BUSINESS

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.

Revised 9/2015

REGISTRATION: Indicate registration(s), license(s), or certification(s) in all states, including Wyoming, where you are currently or have been previously registered, licensed or certified in any profession. Begin with your original registration, license or certification. Note carefully any registrations, licenses or certifications not currently in good standing. Refer to the application instructions for additional direction. 9.

STATE(S) CERTIFIED

CERTIFICATE NUMBER

ISSUE DATE

EXPIRE DATE

CURRENT STATUS

Addictions Therapy Clinical Social Work Marriage and Family Therapy Professional Counseling *Any Other Discipline *Specify certification title and level if applicable: 10. EDUCATION: List any universities or colleges attended that satisfy the educational requirement in the discipline for which

licensure or certification is sought. Refer to the application instructions for additional direction. UNIVERSITY/COLLEGE

CITY/STATE

DEGREE(S)

DATE(S)

MAJOR(S)

11. PROFESSIONAL REFERENCE: Name three (3) persons who will be submitting professional reference forms to the Board. Refer

to the application instructions for additional direction. NAME

ADDRESS

TELEPHONE

(

)

(

)

(

)

12. CERTIFICATION: Indicate professional certifications/credentials which you currently or have previously held in any mental health

discipline, from organizations such as NBCC, NASW, NAADAC, AAMFT, etc. Refer to the application instructions for additional direction. PROFESSIONAL ORGANIZATION

Revised 9/2015

CERTIFICATION TYPE AND NUMBER

ISSUE DATE

EXPIRE DATE

CURRENT STATUS

13. EXPERIENCE: List below your training/work experience. Begin with today and work back in time. Note any interruptions in time,

such as periods of unemployment and/or education. Refer to the application instructions for additional direction. From:

To: Month/Year

Supervisor: Month/Year

Organization: Address:

Brief Description of Work:

From:

To: Month/Year

Supervisor: Month/Year

Organization: Address:

Brief Description of Work:

From:

To: Month/Year

Supervisor: Month/Year

Organization: Address:

Brief Description of Work:

From:

To: Month/Year

Organization: Address:

Brief Description of Work:

Revised 9/2015

Supervisor: Month/Year

HISTORY 14.

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

15.

Has any state rejected or denied your application for certification or licensure in any profession?

 Yes  No

16.

Has any state revoked, suspended, refused to renew, or otherwise restricted your certificate or license in any profession?

 Yes  No

17.

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  No

18.

Have you ever been sanctioned by a professional association?

 Yes  No

19.

Have you been convicted of a misdemeanor involving moral turpitude, including pleas of nolo contendere or no contest?

 Yes  No

20.

Have you been convicted of a felony in any profession, including pleas of nolo contendere or no contest?

 Yes  No

21.

Are you addicted to, or do you habitually use alcohol, any controlled substance, or other drugs having similar effects?

 Yes  No

22.

Have you ever been judged incompetent by a court of law?

 Yes  No

23.

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 14 through 23 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

Revised 9/2015

DATE

MENTAL HEALTH PROFESSIONS LICENSING BOARD 2001 Capitol Ave, Room 104 Cheyenne WY 82002 http://mentalhealth.wyo.gov

PROFESSIONAL REFERENCE Please type or print legibly, preferably in blue ink. The Board will only accept originally signed references. To:

Mental Health Professions Licensing Board

From: Date: Applicant: The person named above has made an application to become licensed or certified as a mental health professional in the state of Wyoming. Applicants are required to demonstrate their integrity, professionalism and character in the field through professional recommendations which attest to applicants’ abilities and professional performance. Board Rules and Regulations require individuals providing professional references to have at least six (6) months of direct knowledge of such experience by the applicant. Please respond to the following questions: 1.

How long have you known the applicant?

2.

What is your relationship to the applicant?

3.

Please describe the situations in which you have observed the applicant engaged in clinical practice.

4.

Is the applicant currently engaged in clinical practice?

5.

In your opinion, does the applicant possess the personal and professional integrity to practice clinically in the  Yes mental health field?

6.

How does the applicant demonstrate respect for the client-therapist relationship?

 Yes  No

(Comments?)

 No

(Comments?)

Revised 8/2013

7.

How does the applicant demonstrate knowledge regarding current ethical issues in clinical mental health practice?

8.

To your knowledge, has there ever been any concern regarding this applicant’s ethical conduct?

 Yes  No

(Comments?)

9.

Do you have any reason to believe that this applicant should not be granted licensure or certification in a mental health profession?

 Yes  No

(Comments?)

10.

Do you believe that on an overall basis, including ethics, conduct, character, and competence, this applicant is or would be a credit to the mental health profession?

 Yes  No

(Comments?)

SIGNATURE

DATE TELEPHONE NUMBER(S): (

Address:

)

Street Address

Business

( City

State

Zip

) Cell

E-mail Address: Please provide an e-mail address that you check regularly. If there are any questions or issues regarding your reference, the Board staff will communicate with you at this address.

Per Wyoming Statute § 16-4-203(d)(iv) letters of reference are not subject to the public right of inspection. Therefore, any comments that you provide will remain confidential between yourself and the Board. The signed reference may be e-mailed to [email protected], or faxed to (307) 777-3508, or mailed to the address provided on this form.

Revised 8/2013

SUPERVISION AGREEMENT Please indicate if this form is for:  Adding supervisor (additional employment)  CERTIFICATE HOLDER  PROVISIONAL LICENSEE DESIGNATED QUALIFIED CLINICAL SUPERVISOR

 A first agreement

 Changing supervisors

Name:

Name:

Email: Provide employment Information below:

Email: Check here if your employer information is the same as Supervisor's

Employer Name

Employer Name

Employer Address

Employer Address

City, State Zip

City, State Zip

Phone Number

Phone Number

We understand and agree to abide by the following guidelines: Clinical practice shall not be permitted, until this Supervision Agreement has been approved by the Board. Individual and/or triadic face-to-face supervision shall be obtained weekly at a ratio of one (1) hour for every twenty (20) hours of direct clinical provision of services defined by Chapter 18 of the rules. The Certificate/Provisional License Holder shall only provide services under the administrative supervision by their employer, and the ongoing direct clinical supervision of the Designated Qualified Clinical Supervisor (DQCS). The Certificate Holder/License Holder shall adhere to the applicable code of ethics and standards of practice for their discipline. In the required professional disclosure statement, the Certificate/Provisional License Holder shall provide to every client full disclosure of the supervised nature of their work, which shall include the name, address and telephone number of their DQCS. The supervisory relationship shall be indicated, and the DQCS’s name, address and telephone number shall appear on all documents relating to advertisement by the Certificate Holder. The DQCS shall allow the Certificate/Provisional License Holder to perform independently only those functions for which they have training and experience. The DQCS shall keep records verifying the supervision of the Certificate/Provisional License Holder, including the precise nature and number of hours of supervision. For provisional supervisees the DQCS shall complete a Verification and Evaluation of Supervised Experience report and submit to the Board with a final recommendation due upon completion of the supervision.

The DQCS shall be identified on all reports and correspondence of a professional nature, excluding disciplinary correspondence with the Board. The DQCS assumes professional and ethical responsibility and may be sanctioned by the Board for all acts and omissions of the Certificate/Provisional License Holder within the scope of the supervision. For provisional licensees accumulating hours towards licensure: Supervised clinical training/work experience hours and face-to-face clinical supervision hours completed in the absence of a Board approved supervision agreement shall not be accepted towards meeting the requirements for licensure. DESIGNATED QUALIFIED CLINICAL SUPERVISOR Signature No digital or stamped signatures

CERTIFICATE HOLDER/PROVISIONAL LICENSEE Date

Signature No digital or stamped signatures.

Date

I have updated my Professional Disclosure Statement which includes the changes to my supervisor and/or employment. Acknowledge by initialing here ________. Any changes in supervision shall be submitted to the Board for approval within ten (10) days of the change.

The signed agreement may be e-mailed to [email protected], faxed to (307) 777-3508, or mailed to Mental Health Professions Licensing Board, 2001 Capitol Ave, Room 104, Cheyenne WY 82002 Please ONLY send ONE copy through one method above.

Effective Date of Agreement:

Board Representative:

Refer to the current STATUTE and RULES AND REGULATIONS for additional details.

Revised 9/2015