LISW-S Supervision Registry Memorandum of Understanding

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LISW-S Supervision Registry Memorandum of Understanding
The NASW Ohio Supervision Registry is available to NASW Ohio members as a member benefit. You
must be a LISW-S and NASW member to be listed in the registry. Please refer to the NASW Ohio website
for the list of qualifications required to be listed in this registry.
A listing in the NASW Ohio registry is not an endorsement of any supervisor or a verification of their
qualifications. It is only a listing provided as a service to members, allowing social workers to review and
select potential supervisors.
By completing and submitting this form, you attest that you meet the qualifications of NASW Ohio for a
listing in the registry, and you agree to abide by the terms and conditions governing such listing (see
Memorandum of Understanding on page 3).
Once you have completed and signed this application, please return it to NASW Ohio Chapter by mail
(33 N Third St, Suite 530, Columbus, OH 43215), email ([email protected]), or fax (614-461-9793).
Incomplete or unsigned applications will not be processed.
ANY OR ALL OF THE INFORMATION ON THIS APPLICATION MAY BE POSTED ON THE NASW OHIO
WEBSITE IN THE “SUPERVISION REGISTRY” SECTION. THE ASTERISKED SECTIONS BELOW INDICATE
WHAT INFORMATION WILL BE VIEWABLE.
PART I
*Last Name:
*First Name:
Street Address (where people seeking supervision will find you)
*City:
State:
Zip:
*County:
*Phone:
*Email Address (required):
How do you prefer to be contacted by potential supervisees?:
Social Work License Number:
NASW Membership Number:
Liability Insurance Carrier:
Policy/Plan Number:
Education (list college/university where degree was received only):
Bachelor’s Degree:
Master’s Degree:
PhD:
Other:
Languages (other than English) in which you are fluent:
Number of years you have been providing one-on-one social work supervision:
Please describe your experience with supervision:
Environment in which you are now employed:
__ Private Practice
__ Nursing Home
__ Mental Health Agency
__ School
__ ATOD Agency
__ Retired
__ Hospital
__ Other (please specify): _________________________
Other Credentials: PLEASE CHECK ALL THAT APPLY AS THEY WILL BE USED IN SEARCH CRITERIA
YES
NO
ACSW
DCSW
QCSW
LCDC III
LICDC
OCPS I
OCPS II
Pupil Personnel License (ODE)
Other (Please specify):
AREAS OF SPECIALIZATION
State areas of competence. You may include areas of cultural competence; age or specific types of
population(s); specific types of therapeutic modalities; etc.
PART II
MEMORANDUM OF UNDERSTANDING
I hereby attest that:
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I am a Licensed Independent Social Worker with Supervisory Designation (LISW-S) in the state of
Ohio, in good standing
I have never received any negative sanctions from the Counselor, Social Worker and Marriage and
Family Therapist Board
I am a current member of NASW Ohio Chapter
I have provided my statement of experience
I have professional liability insurance of at least $1 million
I am familiar with and adhere to the NASW Code of Ethics
I further agree that:
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I will continue to comply with the NASW Code of Ethics
I will notify NASW Ohio immediately if my LISW-S is revoked, suspended, voluntarily terminated,
expires or for any other reason becomes invalid
I will notify NASW Ohio within thirty (30) days if any of the other information I have provided on my
application changes, and
I will provide to NASW Ohio, upon request, non-identifying information to assist in evaluating the
effectiveness and value of the Supervision Registry
I understand that NASW Ohio provides the Supervisor Registry as a service available to members of NASW
Ohio. It is my responsibility to ensure NASW Ohio has my current, accurate information and to notify NASW
Ohio in the event any of my information changes. I also understand I may request removal from the
Supervisor Registry at any time.
I understand that upon approval of my application, NASW Ohio will post the information provided in my
application on a page of the NASW Ohio website. NASW does not control and is not responsible for how
individuals use the information posted. NASW Ohio may contact me from time to time to obtain nonidentifying information about my experience with the Supervision Registry.
Payment arrangements for supervisory services are between me as the Supervisor and the Supervisee
only. Neither NASW Ohio nor NASW, the CSWMFT Board, nor any of their employees, officers, board
members nor volunteers will be a party to any transaction between Supervisor and Supervisee, nor will
any of them be liable for any actions or inactions of either Supervisor or Supervisee.
NASW Ohio reserves the right in its discretion to remove my listing from the Supervision Registry
immediately under circumstances including, without limitation:
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Any information I have provided in connection with the Registry is found to be false
My LISW-S lapses
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I fail to maintain my NASW membership in good standing
I fail to cooperate with the requirements of the Registry program, e.g., failure to provide a timely
update prior to the annual renewal
I am found to be in violation of the NASW Code of Ethics or state CSWMFT board rules and
regulations
NASW receives a request for professional review of my conduct under the NASW Code of Ethics
A complaint against me is upheld by the Ohio licensing board, or
A criminal complaint against me is pending or upheld
Any change in state law or NASW requirements that necessitates modification of the Registry
I agree to indemnify NASW Ohio, NASW, the CSWMFT Board, their employees, officers, board members
and volunteers and hold them harmless from any liability arising in connection with my participation in
the Supervision Registry or my relationship with any potential Supervisee who contacts me as a result of
my Registry listing.
I certify that the information contained in this application is accurate and complete to the best of my
knowledge and is made in good faith. I further understand that if any information is later determined to
be false, NASW Ohio reserves the right to remove this listing from its directory, and any fees paid by me
shall not be refunded.
SIGNATURE:
FULL NAME (PLEASE PRINT):
DATE SIGNED:
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