FORM 1C
Initial Application Clinical Social Work Reference
This form must be completed on a computer: space will expand as required. Handwritten forms will not be
accepted. Each supervisor named in the Proposed Supervision Plan must complete this form and submit it directly
to the ACSW. A copy should be maintained by the Supervisor of Record.
Clinical Social Work is a mental health profession based on the application of knowledge and theory of “psychosocial
development, behaviour, psychopathology, unconscious motivation, interpersonal relationships and environmental
stress”*. It utilizes social work methods to assess, diagnose and provide psychotherapeutic interventions across the
lifespan with individuals, couples, families and groups. Clinical Social Workers demonstrate a commitment to continue
competence, ethical practice and respect for diversity.
Clinical social workers who have received the appropriate training are qualified to use the Diagnostic and Statistical
Manual of Mental Disorders (DSM), International Classification of Diseases (ICD), Person-in-Environment
Classification System (PIE), and other diagnostic classification systems, psychometric instruments, and personality
inventories, in assessment, diagnosis, treatment, and other activities.
* Handbook of Clinical Social Work Supervision (3rd edition) Carlton E. Munson, PhD p. 9.
Name of applicant to the Clinical Specialty Registry:
Part A:
Supervisor Name:
Academic degree(s):
Professional Designation:
Registration #:
Job/position title:
Who is your employer?
How long have you been in your present position?
What are your major job responsibilities?
What is your role in the supervision plan?
Please provide telephone numbers where we may reach you if we have any questions about your comments
on this form or require additional information: Home:
Office:
Part B:
How long have you known the applicant?
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FORM 1C
What was the duration of your professional relationship with the applicant? ______________________
In what capacity(ies) do you or have you known the applicant? (Please check all that apply)
business partner
classmate
colleague
co-worker
friend
your instructor
member of peer supervision
team or consultation group
your student in field
placement
your student in class
partner/spouse
other relative
other (please specify):
your supervisor
your supervisee
consultant
mentor/coach
Part C:
Have you been directly responsible for either of the following with this applicant?
a. clinical supervision
Yes
No
b. professional consultation
Yes
No
If yes, please provide the following information:
What date (approximately) did you begin providing clinical
supervision/consultation to this applicant?
What date (approximately) did you last provide clinical
supervision/consultation to this applicant?
In what setting do/did you provide clinical supervision/
consultation to this applicant?
How long were you this applicant’s clinical supervisor/consultant?
How often did you provide individual supervision/consultation for
this applicant?
How often did you provide group supervision/consultation for this
applicant?
Please estimate the total number of clinical supervision/
consultation hours you have provided to this applicant to date:
Part D:
In your professional judgment, does this person practice “clinical social work” according to the definition on page
1 of this form?
Yes
No
Please explain:
The Clinical Committee has adopted the definitions of progressive levels of professional competence as
established by the American Board of Examiners in Clinical Social Work, as stated below.* For more information
on how to interpret these definitions, please go to http://www.abecsw.org/images/Competen.PDF
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FORM 1C
(1) Postgraduate Practice Level (MSW Level)
The MSW level provides a basic preparation for clinical social work practice. The typical MSW curriculum
provides students with an overall orientation to the field of professional social work; a basic grounding in theories
of social work practice and application of these theories to practice; an exposure to generic practice methods; and
a foundation in the values and ethics of the profession.
 Expand the diversity of their clinical experiences
 Increase their knowledge of the legal and ethical parameters of practice
 Enhance their practice skills
 Learn to identify clients who are at risk and to intervene appropriately
 Augment their repertoire of practice theories and methods
 Mature in the professional use of self
 Increase their ability to differentiate clinical observations from inferences
 Achieve integrity of their professional beliefs
 Increase confidence in their clinical judgment through self study of practice and clinical supervision.
 Define their professional stance vis-à-vis the reality of the practice environment
 Understand and accept their practice limitations
 Develop a concept and a plan for their future professional development
(2) Autonomous Practice Level
Autonomous practice is practice that is not under clinical supervision—whether inside or outside an agency
structure. This level of professional development reflects mastery of practice competencies. Autonomous
practitioners are expected to be able to assume clinical responsibility for the diagnosis, assessment and treatment
of their clients, deciding for themselves when consultation is necessary. Achievement of the following skills
indicates that the practitioner has reached the autonomous practice level:
 Provides adequate clinical diagnoses and biopsychosocial assessments
 Performs short- and/or long-term interventions
 Establishes treatment plans with measurable goals
 Adapts interventions to maximize client responsiveness
 Demonstrates competence in clinical risk assessment and intervention
 Recognizes when personal issues affect clinical objectivity
 Recognizes and operates within own practice limitations
 Seeks consultation when needed
 Refers to sources of help when appropriate
 Practices within established ethical and legal parameters
(3) Advanced Practice Level
The advanced practice level required a five-year minimum of practice experience beyond graduation as an MSW,
plus the achievement of the autonomous practice level. Advanced clinical social orkers are expected to have
reached the full integration of a professional self and have affirmed their professional role and identity; to
recognize that the relationship between theory and practice is often problematic and that theories of development
and practice skills require constant emendation (Fook, Ryan and Hawkins, 1997). Advanced clinical social
workers are expected to have mastered the skills required for autonomous practice with diverse populations, and
may have also developed mastery of specialized areas of clinical practice. Additionally, advanced clinical social
workers may have acquired the skills to supervise, consult, teach, and otherwise contribute to the professional
development of colleagues. Advanced practitioners demonstrate the following:
 Increased depth and breadth of practice skills
 Independent competence with diverse diagnostic groups
 Ability to adapt core knowledge to unique needs of client and milieu
 Clear definition of limitations in level of expertise and scope of practice
 Continued participation in direct practice activities
 Ongoing motivation for learning from practice experience
 Commitment to and implementation of continuing professional education and development
 Maintenance of highest level of ethical standards for the profession
 Specialization in one or more areas of expertise
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FORM 1C
 Expertise in participating in the professional development of colleagues (through mentorship, supervision
and other modes of teaching)
 Leadership in developing and expanding intervention strategies
 Leadership in defining and attending to professional issues
 Ability to expand the conceptual knowledge of the profession
*Used with permission
The Clinical Social Work Register is intended to identify autonomous clinical practitioners. Using the following
scale, where would you place this applicant?
1 = Post-graduate practice level
2 = Autonomous practice level
3 = Advanced practitioner
Using the same scale of 1 to 3 above, please rank the applicant in each of the following categories in their current
clinical practice:
Practice Indicator
1
2
3
No opportunity to
observe
Provides adequate clinical diagnoses and biopsychosocial assessments
Performs short- and/or long-term interventions
Establishes treatment plans with measurable goals
Adapts interventions to maximize client responsiveness
Demonstrates competence in clinical risk assessment and intervention
Recognizes when personal issues affect clinical objectivity
Recognizes and operates within own practice limitations
Seeks consultation when needed
Refers to sources of help when appropriate
Practices within established ethical and legal parameters
Mature in professional use of self
Able to differentiate clinical observations from inferences
Demonstrates integrity with professional values/beliefs
Demonstrates self-confidence in practice
Able to identify needs and plan for professional development
Able to work with diverse groups/populations
Demonstrates appropriate record-keeping and file management skills
Uses literature and other resource materials to enhance practice
Works collaboratively with other professionals to meet the client’s best interest
Integrates clinical theory into practice meaningfully
Manages professional boundaries appropriately
What social work intervention or theory base underlies the applicant’s practice?
In what ways do you see the applicant demonstrating ethical practice? Please provide an example.
Please identify any concerns you have regarding this applicant’s social work practice:
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FORM 1C
Signature:
Please return directly to:
Date:
Alberta College of Social Workers
#550, 10707 - 100 Avenue
Edmonton, AB T5J 3M1
Please Note: Access to information standards are such that an applicant may have access to this form if their
application for the registry is denied.
Last revised: July 2011
Review date: July 2012
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