New Jersey's Documentation of Supervised Clinical Experience form, explained

One form per supervisor, title and location

The form itself asks for one per supervisor and per title; the Board's FAQ adds one for each location. A new supervisor, a new job title or a move to another location each means another form.

When we checked, the Board's current version was revised April 11, 2025. Download it fresh from the Board when you apply.

What the form asks

• You: your name, your LSW license number and the date you were licensed, and your job title
• Your supervisor: their name, their LCSW license, the date of their initial New Jersey LCSW license, and the date of their 20-hour supervisory certification
• The hours, in sections A, B and C, and the total of the three
• The total months of supervised experience (a minimum of 24), the start and end dates, and whether the months were consecutive
• The agency where you worked and its address
• Your supervisor's averages of hours a week in face-to-face and in group supervision, and the sections your supervisor completes and signs

Sections A, B and C

The form's total adds A, B and C. It doesn't say how assessment hours beyond 960 are treated, and across all your forms, no more than 1,080 non-clinical hours count toward the 3,000, because at least 1,920 of the 3,000 must be face to face (4.1(a)).

• A. Face-to-face clinical client contact: clinical assessment and clinical consultation hours, up to 960 accepted toward your 1,920
• B. Psychotherapy: at least 960 hours
• C. Non-clinical hours, including time in supervision and other social work services: the form says a maximum of 1,080 hours is allowed

Dates and months

The form says “You must include a date by which the hours listed were accrued” and asks you not to include significant gaps in the months. The Board doesn't define a significant gap, or say how to count a part month; ask the Board if your dates leave you unsure.

The experience must have been completed no more than five years before you apply (N.J.A.C. 13:44G-4.1(b)4), so a form for an old job can run out of time.

Who signs and who sends it

• You and your supervisor both sign it
• You upload it to your online profile with your LCSW application; the Board doesn't ask your supervisor to send it
• With it: your supervisor's 20-hour supervision course certificate and CV, your supervisor's separate sheet with "a detailed description of the direct clinical services" you provided under their supervision (the form requires it), and the official HR job description for your title, on agency letterhead and signed by an agency official (not a letter written for you)
• If your supervisor was outside your agency: your employer's notarized letter on agency letterhead, with an original signature, consenting to it and giving a contact name, phone number and email (the Board's FAQ)

If your supervisor can't sign

The Board accepts a notarized affidavit instead, giving the dates, your supervisor's credentials and eligibility, your face-to-face hours, your weekly supervision hours, your title and the HR job description (N.J.A.C. 13:44G-4.1(b)4; the Board's FAQ).

Before you start: the Proposed Plan

The Board's Proposed Plan of Supervised Clinical Experience is optional, costs nothing, and the Board strongly recommends it. It can be submitted before supervision starts or while it is going on, “to allow the Board to approve, deny or offer additional feedback ... before the hours have been completed”. You upload it to your LSW online profile with your supervisor's 20-hour course certificate, the supervisor's resume or CV, the HR job description, and the outside-supervision letter if there is one.

The Plan asks your supervisor: “Do you agree to maintain weekly supervision notes and co-sign a client contact log which shall be made available to the Board upon request?” Keeping your own weekly totals by section, agreed with your supervisor, makes the Documentation form add up when you apply.