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Click ‘Get Form’ to open the experience attestation form in the editor.
Begin by entering the applicant’s name and intern registration number at the top of the form. Ensure that this information is accurate and clearly printed.
Select the appropriate professional category by checking one of the boxes: Clinical Social Work, Marriage & Family Therapy, or Mental Health Counseling.
The supervisor should fill in their general information, including name, phone number, address, license/certification title, state, original licensure date, license number, other professional credentials, organization, original certificate date, and certification number.
In the Supervised Experience Affirmation section, supervisors must confirm their understanding of supervision requirements and provide details about the supervision period and hours worked by the intern.
Check one box regarding the intern's performance standards. If 'has not met' is selected, provide additional information as required.
Finally, ensure that the supervisor signs and dates the form. This step is crucial as it validates the completion of the document.

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