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State of Nevada
Board of Examiners for Social Workers
4600 Kietzke Lane, #C-121, Reno, NV 89502
(775) 688-2555
PLEASE READ BEFORE COMPLETING APPLICATION
Information for Licensure via Post-Graduate Internship
CLINICAL SOCIAL WORKER (LCSW) or INDEPENDENT SOCIAL WORKER (LISW)
Pursuant to NRS 641B.500, it is unlawful for any person to represent him/herself as a social worker
without a license. You may not engage in the practice of social work until you are licensed.
EACH item on the enclosed application must be completed. Once ALL information has been received by the
Board, the application will be processed. Allow forty-five (45) days for processing of the completed application.
Failure to provide requested information will result in a delay or rejection of the application as incomplete.
GENERAL QUALIFICATIONS / REQUIREMENTS
1. Applicant must be at least twenty-one (21) years of age.
2. Applicant must provide one form of identification that verifies birth date, including
a. Copy of birth certificate (Hospital certificates are not acceptable), or
b. Copy of current passport.
3. Applicant must provide a copy of current driver’s license or state identification card.
4. Applicant must possess a Master’s degree in Social Work from a college or university accredited by the
Council on Social Work Education.
5. Applicants must pass the appropriate examination given by the Association of Social Work Boards
(ASWB).
6. Applicant must pass state and federal background checks.
An application for licensure, which is not completed within six (6) months, will be considered closed. The
Board will not refund any fee related to an application, which has closed.
FINAL APPROVAL FOR LICENSURE WILL OCCUR AFTER RECEIPT OF THE BACKGROUND CHECK
REPORTS.
Please refer to NRS 641B and NAC 641B for specific laws and statutes about licensure. Links to these
documents can be found at the Board website - http://socwork.nv.gov/
.
License Types
• LCSW license via completion of a post-graduate clinical internship
• LISW licensure via completion of a post-graduate independent internship
Please use the decision tree below to determine if you are eligible for licensure via a post-graduate internship.
A narrative explanation will follow the decision tree.
DECISION TREE FOR TYPE OF LCSW / LISW INTERNSHIP
Do you have a
master’s degree
in social work
(MSW)?
You are NOT
eligible for a
post-graduate
internship
YES
NO
Do you currently
hold licensure as
a Social Worker
in another state?
Do you currently
hold licensure as
a Social Worker
(LSW) in Nevada?
NO
You are eligible
to apply for an
“Initial” license
via a post-
graduate
internship
YES
Have you passed
the Master’s
exam from
ASWB?
YES
Narrative explanation of LCSW / LISW Internship Types
Initial LCSW / LISW license via Internship
• Master’s Degree in Social Work from a CSWE accredited program.
• Is licensed in Nevada as a Social Worker (LSW).
• Has passed the Master’s examination given by the Association of Social Work Boards (ASWB).
FEES FOR LICENSURE
• Application fee $50.00
• Initial license fee $125.00
Armed Forces Discount on License fee (50% reduction in initial license fee)
• Applicant has verified eligibility as an active member of, or the spouse of an active member of the
Armed Forces of the United States; is a veteran or a veteran’s surviving spouse. Approved verification
information can be found be found on the Board’s website at:
http://socwork.nv.gov/uploadedFiles/socworknvgov/content/licensees/Attachment2.pdf
Board of Examiners for Social Workers
Application for Clinical Social Worker License (LCSW) or
Independent Social Worker (LISW) via Internship
Please read instructions before completing this fillable form or print in blue or black ink.
General Information:
Present Legal Name:
Last First Middle
List any other name(s) ever used:
Mailing Address:
Street City State Zip
Telephone ( )
Social Security Number: OR
ITIN Number:
Date of Birth:
Email Address (mandatory):
The Board will use this email address to communicate with you. This email address will be added to the Board
Listserv, which is used to disseminate information pertinent to all licensees.
License Information:
What license type are you applying for (see instructions for description)?
Initial LCSW licensure via a post-graduate internship
Initial LISW licensure via a post-graduate internship
Are you currently, or have you ever been licensed, registered or certified as a Social Worker in another state(s)?
No Yes If “yes,” list state(s)
Have you ever passed an ASWB examination? No Yes If “yes,” date taken
If “yes,” which level? Bachelors Masters Advanced Generalist Clinical
What other professional Nevada state licenses or certifications do you currently hold?
Board Use Only
Date Received Amount
Check #
Money Order #
EFT Payment
Rev. 11/18 5
Employment History:
List ten (10) years of work history in chronological order beginning with most recent (explain any gaps in employment,
i.e. attending school, raising children, etc.). You must account for all the time, even if you were not working.
Add additional sheets if necessary.
Employer Address Telephone
Position Supervisor Dates of Employment
Duties
Employer Address Telephone
Position Supervisor Dates of Employment
Duties
Employer Address Telephone
Position Supervisor Dates of Employment
Duties
Employer Address Telephone
Position Supervisor Dates of Employment
Duties
Employer Address Telephone
Position Supervisor Dates of Employment
Duties
E
ducation Information:
A copy of a certified transcript showing the highest degree awarded must be received directly from the school.
N
ame of School Location Major
Degree
Awarded
Degree Date
Rev. 11/18 6
Screening Questions: If you answered “yes” to any of the following five (5) questions, you must provide the Board
with requested information as detailed below.
Yes
No
gross misdemeanor or felony (other than a minor traffic violation)?
Information provided will be compared to the information received from the legal background
check. If this information does not match, the application process will be pended until the
discrepancies are addressed to the Board’s satisfaction.
If you answered “yes” to this question, you must provide the following information –
• A list of your arrest(s), charge(s) and / or conviction(s) in chronological order.
• A court certified copy of records pertaining to arrests, charges and / or convictions from the Court Clerk in the
community where the incident(s) occurred.
• A court certified copy of final or most recent disposition of your case(s) from the Court Clerk of the court in whic
h
c
onvicted.
• A letter from you describing the underlying circumstances of your arrest(s), charge(s) and / or conviction(s)
including the nature of the act(s) or crime(s) and the date(s) of the crime.
• A letter from you describing your rehabilitation efforts or changes you have made to prevent future problems.
It is your responsibility to present enough evidence of rehabilitation to demonstrate your fitness for
licensure. The Board may request additional information as it deems necessary.
Yes
No
2. Have you ever been denied a license or certification or been denied approval to take
a l
icensing examination?
professional license or certification?
incompetence?
If you answered “yes” to any of these questions, you must provide the following information –
• A letter from you describing the circumstance of the incident.
• A certified copy of the determination made by the licensing or professional entity.
• If disciplinary action was imposed, the above document should include date and location of the incident,
specific violation, date of disciplinary action, and sanctions or penalties imposed.
• If disciplinary action was imposed, a letter from you describing rehabilitation efforts or changes you have made
to prevent further problems.
• A letter from you describing your rehabilitation efforts or changes you have made to prevent future problems.
It is your responsibility to present enough evidence of rehabilitation to demonstrate your fitness for
licensure. The Board may request additional information as it deems necessary.
Yes
No
substance abuse, alcohol abuse, mental and / or medical condition) which currently
affects your ability to deliver essential social work services?
If you answered “yes” to this question, you must provide the following information –
• A letter from you describing the circumstances.
The Board may request additional information as it deems necessary.
Rev. 11/18 7
Child Support Information: Please check the appropriate answer. It is mandatory that you answer this question.
a. I am not subject to a court order for the support of child.
b. I am subject to a court order for the support of one or more children and am in compliance with the order
or am in compliance with a plan approved by the district attorney or other public agency enforcing the
or
der for the repayment of the amount owed pursuant to the order.
c. I am subject to a court order for the support of one or more children and am not in compliance with the
order or a plan approved by the district attorney or other public agency enforcing the order for the
repayment of the amount owed pursuant to the order.
A
rmed Forces / Veterans: Please check the appropriate answer. The term “veteran” has the meaning ascribed to
it, pursuant to NRS 417.005.
a. I have NO SERVICE in the Armed Forces, Commissioned Corps of the United States PHS or the
Commissioned Corp of NOAA and served in the capacity of a commissioned officer while on active duty.
b. I am an active member, or spouse of an active member of the Armed Forces.
c. I am a veteran, or spouse of a veteran of the Armed Forces.
d. Other – Commissioned Corps of the U.S. PHS or the Commissioned Corps of NOAA and served in the
capacity of a commissioned officer while on active duty.
I
have read all questions, answers and statements and know the content thereof. I hereby certify under the penalty of
perjury that the information furnished on this document is true and correct.
I
hereby authorize the Board of Examiners for Social Workers, its agents and employees, to conduct any investigation(s) of
my business, professional, social and moral background, qualifications and reputation, as it may deem necessary, proper
or desirable. No liability of any sort or kind shall attach itself to the said Board of Examiners for Social Workers, its members,
or employees or by reason of the use of the authorization.
Dated Signature of Applicant
State of
County of
Subscribed and sworn to before me this
day of
Month / Year
By
Signature of Notary
Notary Public for State of
My commission expires
Notary Seal
CLINICAL / INDEPENDENT INTERNSHIP APPLICATION
Th
e following to be completed by Intern Applicant
T
ype of Internship: Clinical Independent
Present Legal Name:
Last First Middle
Mailing Address:
Street City State Zip
Telephone ( ) LSW License Number:
Email Address (mandatory):
Proposed Internship Site One (1) Name:
Site Address:
Street City State Zip
Site Telephone ( )
Job Title
Anticipated Internship Hours Per Week
I have included a copy of the job description I will be working under with this application. Yes
Proposed Internship Site Two (2) Name:
Site Address:
Street City State Zip
Site Telephone ( )
Job Title
Anticipated Internship Hours Per Week
I have included a copy of the job description I will be working under with this application. Yes
Rev. 11/18
9
To Be Completed by Internship Supervisor
Present Legal Name:
Last First Middle
Mailing Address:
Street City State Zip
Telephone ( )
Nevada Clinical Social Work (LCSW) or Independent Social Work (LISW) license number:
Email Address (mandatory):
Are you an employee of, or contracted with, the proposed Internship Site one (1)? Yes No If “no,” who is
the licensed on-site mental health professional (include his/her licensure)
Are you an employee of, or contracted with, the proposed Internship Site two (2)? Yes No If “no,” who is
the licensed on-site mental health professional (include his/her licensure)
Are you able to demonstrate at least three (3) years of experience as a licensed clinical social worker or independent social
worker? Yes No
Have you completed an intern supervisor training workshop in the last five years? Yes No
Are you able to demonstrate that your current practice consists of not less than 15 hours per month of practice?
N/A Yes No
Do you or have you ever had any business or personal relationship with the applicant? Yes No
Do you or have you ever had a client relationship with the applicant? Yes No
Number of social work interns you currently have under your supervision (not including this applicant)?
If this is your first time as an intern supervisor, please attach a copy of your current resume and list the names, addresses
and telephone numbers of three (3) references that are able to critique your qualifications as a social worker and
supervisor of social worker interns.
Supervisor’s
Initials
Supervisor assures that the intern will be properly trained to administer and score the following list
of assessment tools used in the agency, prior to implementing use of them. Assessments used
are –
Agency provides secure storage for client files, including transportation of client files if these
files are taken out of the Agency (e.g. to provide in-home services).
If the intern will be providing services, including therapy, AWAY FROM THE AGENCY, supervisor
confirms that there is a clear safety plan, including an on-call list for the intern to use if needed.
SUPERVISOR - My initials serve as certification of items initialed above.
Supervisor’s Name:
Initials
S
ignature
Date
CLINICAL / INDEPENDENT INTERNSHIP SUPERVISION CONTRACT
A
rticle I PARTIES
This contract is made by and between and
Intern Supervisor
hereafter referred to as Intern and Supervisor, respectively.
Article II PURPOSE
The purpose of this agreement is the provision of internship supervision for the practice of clinical social work or independent
social work in Nevada as defined by Nevada Revised Statute (NRS) 641B.
Article III TERM
This contract is effective from and will remain in effect until unless
month / day / year month / day / year
unless terminated by the Intern or Supervisor after thirty (30) days advanced written notice. Duration and termination of
internships and internship supervision is subject to conditions specified by Nevada Revised Statute (NRS) 641B and Nevada
Administrative Code (NAC) 641B.
Article IV INTERNSHIP SITE(S)
Internship Site One (1):
Internship Site Two (2):
Intern and Supervisor agree and declare that no practice shall be engaged in outside of the site(s) listed above.
Article V INTERNSHIP CONTENT AND PROCESS
Content: Intern and Supervisor agree the content of the internship learning experience will adhere to the Board of
Examiners for Social Workers “Learning Objectives” for clinical or independent internships as available on the Board
website. www.socwork.nv.gov
.
Process: Intern and Supervisor agree that the process of the internship learning experience will comply with Nevada
Administrative Code (NAC) 641B.140 through 641B.170 as available on the Board website. www.socwork.nv.gov
.
Intern and Supervisor agree to establish supervision scheduled no less than one (1) hour per week.
Article VI COMPENSATION FOR SUPERVISION
Intern agrees to pay Supervisor $ per hour for supervision provided during the contract period.
Supervisor agrees to do monthly on-site visits at any site that they are not employed at or contracted with.
Article VII GENERAL PROVISIONS
This agreement supersedes any and all other agreements, oral or written, between Intern and Supervisor hereto with
respect to the rendering of supervision of Intern by Supervisor. This document contains all of the covenants and agreements
between Intern and Supervisor with respect to representations, inducements, promises or agreements, orally or otherwise,
made by any party, or anyone acting on behalf of any party, which are not embodied herein, and that no other agreement,
statement or promise not contained in the agreement shall be void or binding.
Any modification of this agreement will be effective only if in writing, signed by Interns and Supervisor, submitted to and
approved by the Nevada State Board of Examiners for Social Workers. Such modifications must be in compliance with
applicable Nevada Revised Statutes and Nevada Administrative Codes.
If any action at law or in equity, including an action for declaratory relief, is brought to enforce or interpret the provisions of
this agreement, the prevailing party will be entitled to reasonable attorney’s fees, which may be set for that purpose, in
addition to any other relief that the party may be entitled.
I
ntern applicants are reminded that a Board approved internship is not a license to independently practice social work in
Nevada. Interns must post, in a conspicuous place, the Board issued internship certificate which clearly identifies the
applicant as an intern and the name of the intern supervisor. Pursuant to NAC 641B.240(2), an intern must use the title
“Intern” in all communications with the Board and his or her respective clients.
The minimum length of an approved internship program is twenty-four months of practice; the internship program
must be completed within thirty-six months from the original approval date unless otherwise approved by the
Board. Extensions are granted for good cause only.
S
upervisors and interns are required to meet for at least one hour every week. There are typically twenty-six (26)
weeks in a reporting period.
Supervisor’s
Initials
Internship will address the following competencies, required for successful completion of the
internship.
Completion of clinical psychosocial assessments and determination of comprehensive diagnoses
using current edition of DSM.
Knowledge and utilization of mental status exams.
Knowledge and use of various assessment tools to assess individuals, couples, families and
groups.
Development and implementation of treatment plans and measurable goals.
Utilization of various clinical intervention approaches in the practice of psychotherapy.
Engagement in psychotherapy with individuals, couples, families and groups.
Review and document treatment outcomes in a timely way.
Knowledge, coordination and use of community, county, state and federal resources.
Knowledge of pharmacology and its impact on clients.
Knowledge of substance and behavioral addictions and related clinical interventions
Completion of evaluations for suicidal / homicidal ideation and use of related interventions (to include
legal holds and duty to warn).
Understanding of mandated reporting of child abuse, elder abuse, and abuse of vulnerable
populations and related interventions
Engagement with a wide range of clients and diagnoses.
Understanding the parameters of client confidentiality and the legal / ethical ramifications pertaining
to social work practice.
Knowledge and implantation of ethical and cultural considerations in clinical practice.
Utilization of supervision for a critical review of practice.
Connecting social work goals, values and ethics to administrative responsibility to clients, agency
and community.
Intern engages in self-evaluation, to include awareness of and conscious use of self in practice.
Understanding of safety considerations, managing crisis situations and risk management issues
related to clients.
Understanding of NRS 641B and NAC 641B as governing language about the practice of social work.
Connecting NASW Code of Ethics to Nevada laws.
Competence in the use of technology associated with practice and telehealth as a method of
treatment.
Understanding of agency operations, including funding sources, billing for services, payment for
services and collections.
Other:
Other:
This agreement shall be governed by and constructed in accordance with the laws of the State of Nevada.
Dated Signature of Intern
Dated Signature of Supervisor
State of
County of
Subscribed and sworn to before me this
day of
Month / Year
By
Signature of Notary
Notary Public for State of
My commission expires
Notary Seal
Application Checklist – LCSW / LISW Internship
The following items are required with your application.
Please use the checklist to ensure that you have given us all the information we require. Failing to
provide the required information will delay your application.
Initials
License Application with all information provided. Signatures are notarized.
GENERAL FEES – ALL APPLICANTS
Application Fee of $50.00
Licensure Fees (select ONE)
Initial License Fee of $125.00 OR Armed Forces Initial License Fee of $62.50
TOTAL FEES SUBMITTED $
This can be a personal check, cashier’s check or money order made out the Board of
Examiners for Social Workers. A $30.00 fee is assessed on all returned checks.
Copy of Birth Certificate or Passport OR Naturalization Documents OR Documentation from the
United States Immigration and Naturalization Service evidencing the lawful entitlement of the
applicant to remain and work in the United States.
Copy of current, legible, official government photo identification (i.e. Driver’s License)
Copy of all legal documents verifying all name changes from birth (including birth certificate).
Fingerprint packet IF background check for LSW license is more than six (6) months old
• Two (2) complete sets of fingerprint cards (Form FD-258) – one (1) for FBI and one (1) for
state.
• Signed Fingerprint Waiver form,
• A money order in the amount of $40.25 made payable to the Nevada Dept. of Public Safety
(NV DPS).
I have requested certified transcripts be sent directly to the Board verifying my coursework and
degree from the university where I received my highest social work degree.
This is in addition to the transcripts requested for your LSW file.
Initials
Internship Application with all information provided.
Job Description(s) for internship position(s)
Supervision Contract
Access Letter (if supervisor is not employed / contracted by the agency where internship will be
completed)
My initials serve as acknowledgement of inclusion of required items or requests for items required for license
application. Include this document with your application.
Applicant’s Name:
Initials Signature Date
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Board of Examiners for Social Workers PLEASE READ (State of Nevada, Department of Information Technology)

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Completed 8 March 2022

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