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4.MAXIMUM RENEWALS AND ISSUANCE OF SUBSEQUENT REGISTRATIONSYour registration can be renewed five (5) times, for a total six (6)-year length. If you needto retain a registration after this time, you will need to apply for a subsequent registrationnumber. A subsequent registration can only be issued to applicants who have passedthe LCSW California Law and Ethics Exam (or the former LCSW Standard WrittenExam).5.ABANDONMENT OF APPLICATIONIn accordance with Title 16, California Code of Regulations (CCR) section 1806, anapplication shall be deemed abandoned in either of the following circumstances: You do not submit evidence that you have cleared the deficiencies specified in thedeficiency letter within one (1) year from the date of the initial deficiency letter OR You do not complete your application within one (1) year after it has been filed.To re-open an abandoned application, you must submit a new application, fee and allrequired documentation, as well as meet all current requirements in effect at the time thenew application is submitted.6.PUBLIC ADDRESS and CHANGE OF ADDRESSThe address you enter on any Board form is public information and will be placed on theInternet pursuant to Business and Professions Code (BPC) section 27. If you do not wantyour home or work address available to the public, use an alternate mailing address, suchas a post office box. California law requires all persons regulated by the Board to notify theBoard within 30 days of any change of address.7.STATUTES AND REGULATIONSTo obtain a copy of the Board’s Statutes and Regulations, please download it from theBoard’s website.37A-518 (Revised 01/2021)2

8.ADDITIONAL TRAINING OR COURSEWORK REQUIRED FOR LICENSUREVerification of training or coursework can be submitted with this application OR with theApplication for Licensure. Only coursework that meets the criteria specified by law will beaccepted. For more information, see the Board’s Statutes and Regulations.CourseSuicide Risk Assessment andInterventionRequired of:LengthAll applicants6 hours ofcoursework orappliedexperienceContent RequiredSee BPC section4996.27Child Abuse Assessment andReporting in CaliforniaAll applicants7 hoursSee BPC section 28and 16CCR section1807.2. Coursemust be based onCalifornia law.Human SexualityAll applicants10 hours16 CCR section1807Alcoholism and ChemicalSubstance Abuse &DependencyAll applicants15 hours16 CCR section1810Aging, Long Term Care andElder/Dependent Adult AbuseApplicants who entered aMSW program after1/1/2004California Cultures and theSocial and PsychologicalImplications of SocioeconomicPosition (OUT-OF-STATE)Spousal/Partner AbuseAssessment, Detection, andIntervention (OUT-OF-STATE)Spousal/Partner AbuseAssessment, Detection, andIntervention(IN-STATE)10 hoursBPC section4996.25(a)All applicants with out-ofstate education15 hours or 1semester unitBPC section4996.17.2All applicants with out-ofstate education15 hoursBPC 4996.17.2All in-state applicantsEXCEPT for those whoentered a MSW programprior to 01/01/1995 No specific number ofhours for those whoentered a MSWprogram prior to12/31/03, but must be ofsufficient length to coverthe topics ofassessment, detectionand intervention 15 hours for those whoentered a MSWprogram after 1/1/200437A-518 (Revised 01/2021)3BPCsection4996.2(f)

9. AMERICANS WITH DISABILITIES ACTThe Board does not discriminate on the basis of disability in employment or in theadmission and access to its programs or activities. The Executive Officer of the Board hasbeen designated to coordinate and carry out this agency’s compliance with thenondiscrimination requirements of Title II of the ADA. Information concerning theprovisions of the ADA, and the rights provided hereunder, are available from the ADAcoordinator.10. MANDATORY REPORTERUnder California law each person licensed by the Board of Behavioral Sciences is a“mandated reporter” for both child, elder and/or dependent adult abuse or neglectpurposes. California Penal Code section 11166 and Welfare and Institutions Code section15630 require that all mandated reporters make a report to an agency specified [generallylaw enforcement, state, and/or county adult protective services agencies, etc ] in PenalCode section 11165.9 and Welfare and Institutions Code section 15630(b)(1) wheneverthe mandated reporter, in their professional capacity or within the scope of theiremployment, has knowledge of or observes a child, elder and/or dependent adult whomthe mandated reporter knows or reasonably suspects has been the victim of child abuseor elder abuse or neglect.The mandated reporter must make a report of such abuse or neglect immediately, or assoon as practically possible, in the manner specified in Penal Code section 11166 (forchild abuse or neglect) or in Welfare and Institutions Code section 15630 (for elder ordependent adult abuse or neglect). Failure to comply with the requirements of section11166 and section 15630 is a misdemeanor, punishable by up to six months in a countyjail, by a fine of one thousand dollars ( 1,000), or by both imprisonment and fine. Forfurther details about these requirements, consult Penal Code sections 11164 and Welfareand Institutions Code section 15630, and subsequent sections.11.SOCIAL SECURITY NUMBER OR OTHER TAXPAYER IDENTIFICATIONNUMBERIDisclosure of your tax identification number on your application is mandatory. You mayprovide either your Social Security Number, your Federal Employer IdentificationNumber, or Individual Taxpayer Identification Number, as applicable. Section 30 of theBusiness and Professions Code and Public Law 94-455 (42 USCA 405 (c) (2) (c))authorizes collection of these tax identification numbers. Your tax identification numberwill not be deemed a public record and shall not be open to the public. Your taxidentification number will be used exclusively for tax enforcement purposes, forpurposes of compliance with any judgment or order for family support in accordancewith section 17520 of the Family Code, or for verification of licensure or examinationstatus by a licensing or examination entity which utilizes a national examination andwhere licensure is reciprocal with the requesting state. If you fail to disclose your taxidentification number, your application for initial or renewal license will not be processedAND you will be reported to the Franchise Tax Board, which may assess a 100 penaltyagainst you.37A-518 (Revised 01/2021)4

12. STATE TAX OBLIGATIONPursuant to Business and Professions Code section 31(e), the State Board ofEqualization and the Franchise Tax Board may share taxpayer information with theBoard. If a registrant does not pay their state tax obligation, the individual’s ASWregistration may be suspended.13. NOTICE OF COLLECTION OF PERSONAL INFORMATIONThe Board of Behavioral Sciences of the Department of Consumer Affairs collects thepersonal information requested on this form as authorized by Business and ProfessionsCode sections 27, 30, 114.5, 480, 4996.2, 4996.17, 4996.18, Article 2 of Chapter 14(commencing with section 4992), Title 16 of the California Code of Regulations sections1805 and 1806, and the Information Practices Act. The Board uses this informationprincipally to identify and evaluate applicants for licensure, issue and renew licenses, andenforce licensing standards set by statutes and regulations.Mandatory Submission. Submission of the requested information is mandatory. TheBoard cannot consider your application for registration, licensure or renewal unless youprovide all of the requested information.Access to Personal Information. You may review the records maintained by the Boardof Behavioral Sciences that contain your personal information, as permitted by theInformation Practices Act. See below for contact information.Possible Disclosure of Personal Information. We make every effort to protect thepersonal information you provide us. The information you provide, however, may bedisclosed in the following circumstances: In response to a Public Records Act request (Government Code section 6250and following), as allowed by the Information Practices Act (Civil Code section1798 and following); To another government agency as required by state or federal law; or In response to a court or administrative order, a subpoena, or a search warrant.Contact Information. For questions about this notice or access to your records, you maycontact the Board at (916) 574-7830 or by email at BBS.info@dca.ca.gov. For questionsabout the Department of Consumer Affairs’ privacy policy or the Information Practices Act,you may contact the Department of Consumer Affairs, 1625 North Market Blvd.,Sacramento, CA 95834, (800) 952-5210 or email dca@dca.ca.gov.37A-518 (Revised 01/2021)5

APPLICATION FORBBSASSOCIATE CLINICALSOCIAL WORKERREGISTRATIONBoard of Behavioral SciencesOffice Use Only:Carefully read the Application Instructions FIRSTAttach a 150 FeeSSN or ITIN*Legal Name**Birth Date: mm/dd/yyyy E-Mail AddressLastFirstMiddleIf you have ever been known by another name, list the full name(s) and dates of use below(attach any additional names and dates):Full NameDates of Use (from/to)Full NameDates of Use (from/to)Public Address of Record*** Number and StreetCityStateZip CodeHave you ever served in the United States Armed Forces or theCalifornia National Guard? (OPTIONAL)PhoneYes, CurrentlyYes, Previously No * Disclosure of your tax identification number is mandatory. You may provide either your Social SecurityNumber, your Federal Employer Identification Number, or Individual Taxpayer Identification Number, asapplicable. This number must match the number you provide on your fingerprint forms. See ImportantInformation for Applicants for more information about how your tax identification number is used.** You must use your legal name. Your “legal name” is the name established legally by your birthcertificate, marriage or domestic partnership certificate, or divorce decree (for example).*** The address you enter on this application is public information and will be placed on the Internetpursuant to Business and Professions Code section 27. All correspondence from the Board will bemailed to this address. If you do not want your home or work address available to the public, use analternate mailing address such as a post office box.37A-520 (Revised 01/2022)Page 1 of 3

Applicant Name:LastFirstMiddle1. Have you ever applied for or been issued a license, registration orcertificate to practice clinical social work or any other health careprofession in California or any other state?Yes No If YES, provide the information requested below (continue on an additionalsheet if needed):StateType of License, Registration orCertificateLicense, Registrationor Certificate NumberStatus2. Within the 7 years preceding your submission of thisapplication, were you denied a professional healthcare license (“license” includes registrations,certificates, or other means to engage in practice)OR had a professional health care license orprivilege suspended, revoked, or otherwisedisciplined, OR voluntarily surrendered any suchlicense in California or any other state or territory ofthe United States, or by any other governmentalagency or a foreign country?Yes3. If you hold or have held a license or registration topractice clinical social work outside of California,have you attached an Out-of-State Verification ofLicense or Registration form for each license orregistration held?Yes4. Have you submitted official transcripts verifying yourqualifying master’s degree? See ApplicationInstructions for transcript requirements.Yes – Sealed Transcripts via Mail37A-520 (Revised 01/2022)Page 2 of 3 NoDateIssued If YES, we recommend that you completethe Background Statement form, availableon the Board’s website, to facilitateprocessing of your application.We recommend that you answer “Yes”even if you have previously reported it tothe Board, and indicate the type ofprofessional license that was denied,suspended, disciplined, or surrendered,including the date(s) of the denial,suspension, disciplinary action, You do notneed to resubmit documentationpreviously on file. N/A No Yes – Electronic TranscriptsNo

Applicant Name:LastFirstMiddle5. Applicants with an Out-of-State Degree:Yes N/A Have you completed a 12-hour course in California Law andProfessional Ethics for Clinical Social Workers that covered ALLof the topics listed in the Application Instructions item G asrequired by Business and Professions Code section 4996.17.2?No If YES, enclose a certificate of completion.Note: Applicants with a degree earned in California have alreadymet this requirement and no documentation is necessary.BACKGROUND INFORMATION – RESPONSE IS VOLUNTARY.Some criminal convictions will appear on the Board's background check and may requireadditional investigation prior to a licensing determination. For information on whichconvictions the Board is permitted to consider, see the Criminal Conviction FAQ. All currentlypending criminal actions will appear on the Board’s background check and may requireadditional investigation prior to a licensing determination. You are not required to disclose any past convictions or pending criminal cases on thisapplication. In some cases, voluntarily providing information with the application aboutconvictions that the Board is permitted to consider may help an application get processedmore quickly. You may therefore choose to complete the Background Statement form andsubmit it with your application along with evidence of rehabilitation. The form is available onthe Board's website, and includes areas to report convictions the board is permitted toconsider, or pending criminal actions.You can also submit the Background Statement form and evidence of rehabilitation after yousubmit your application or in response to inquiries from the Board. You may seek legalassistance from a lawyer or legal aid organization before providing any information about yourcriminal history. The Board will not deny your application because you exercised your right not to provide criminal history information in your initial application.NOTE: Knowingly making a false statement of fact that is required to be revealed in thisapplication may be grounds for denial of this application.Signature of Applicant: Date:37A-520 (Revised 01/2022)Page 3 of 3

STATE OF CALIFORNIA - BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCYGavin Newsom, GovernorBoard of Behavioral Sciences)i( BBS1625 North Market Blvd., Suite S200, Sacramento, CA 95834Telephone: (916) 574-7830www.bbs.ca.govLICENSED CLINICAL SOCIAL WORKEROUT-OF-STATE LICENSE OR REGISTRATION VERIFICATIONAPPLICANT: Complete this section authorizing release of information by another state board orlicensing agency. Mail this form and any necessary fees to that state board/licensi0ng agency.Verification For:Name of California Applicant:LastName of Individual to be Verified:Last Applicant Applicant’s SupervisorFirstMiddleDate of BirthFirstMiddleLicense NumberI hereby authorize the release of my information to the California Board of Behavioral SciencesSignature of individual to be verified: Date:STATE BOARD/LICENSING AGENCY: Please return this form to the above address.1. Full name as shown in your records:2. License or Registration Title:3. License or Registration Status:Issue Date:4. Any disciplinary action?Expiration Date: Yes NoSignature of Person Completing FormIf YES, attach an explanation.DateState Board/Licensing AgencyStamp HerePrinted Name and TitleState Board or Licensing Agency NameState37A-526 (Revised 01/2020)Phone Number

STATE OF CALIFORNIA - BUSINESS, CONSUMER SERVICES, ANDHOUSING AGENCYGavin Newsom, GovernorBoard of Behavioral Sciences)¼( BBS1625 North Market Blvd., Suite S200, Sacramento, CA 95834Telephone: (916) 574-7830www.bbs.ca.govINSTRUCTIONS FOR LIVE SCAN FINGERPRINTINGAND PRIVACY NOTICESLive Scan Fingerprinting is available only in California. Live Scan fingerprint results will besubmitted to the Department of Justice (DOJ) and the Federal Bureau of Investigation(FBI) electronically.If you need to have your fingerprints taken in another state, you must use the "hard card"fingerprint method. To request hard cards and instructions, send an email toBBS.Fingerprint@dca.ca.gov with "Fingerprint Hard Cards" in the subject line, and includeyour mailing address. Please be advised that the DOJ processing time for hard cardfingerprints is a minimum of 8 to 12 weeks, or longer. In order to avoid processing delaysand additional costs that result from invalid fingerprint cards, fingerprints must be taken at alaw enforcement agency in the state of residence.Fingerprint Fees - Paid to Live Scan SiteIf you have your prints taken via Live Scan, you must pay the fingerprint fees belowdirectly to the site where you have your Live Scan fingerprints taken:DOJ FINGERPRINT PROCESSING FEE: 32.00FBI FINGERPRINT PROCESSING FEE: 17.00In addition to these processing fees, there may be a service charge associated withthe Live Scan site you visit. The Live Scan service site will collect the above fees at thetime you are fingerprinted. The Live Scan service charge may vary from location tolocation.Complete the Request for Live Scan Service FormYou must complete and submit the attached Request for Live Scan Service form at theLive Scan site. Make sure that the information provided in Section 3 of the form matchesthe information on your BBS application. Once your fingerprints have been scanned, theLive Scan Operator will complete Section 4 of this form and return the second and thirdcopies to you.The second copy of this form, with Section 4 completed by the Live Scan Operator,must be MAILED to the BBS in order to retrieve your fingerprint results from the DOJ.Retain the third copy for your records as a proof of payment.37A-648 (Revised 06/2020)1

Live Scan Fingerprint LocationsYou must visit an approved Live Scan Service Site. Most local Police and SheriffDepartments offer the Live Scan fingerprinting service. Some large school districts,passport services, and stores with generalized fingerprinting expertise may also offer LiveScan. A current listing of Live Scan sites is available on the DOJ website er calling the Live Scan service provider for hours of operation, fees, andappointment times if necessary. You must present valid photo identific

Jan 01, 2020 · obtained at a workplace that, prior to the applicant gaining hours, required Live Scan fingerprinting. The applicant must provide documentation to the Board consisting of a copy of the processed “State of California Request for Live Scan Service” form. This form must be submitted with the