Form DCA BBS 37A-638, Associate Clinical Social Worker (ASW) Weekly Log of Experience Hours Instructions

Enter the associate's family/surname exactly as it should appear on official records.

Enter the associate's given/first name as it appears on official records.

Enter the associate's middle name or middle initial, if any; otherwise leave blank.

Enter the Board of Behavioral Sciences (BBS) file number for this associate if known; enter the identifier exactly as it appears on BBS documents.

Check this box when you are providing your ASW Number in the adjacent ASW Number field (use it to indicate that an ASW Number is being supplied).

Enter the Associate Social Worker (ASW) identification number assigned to the associate, using the exact digits or characters from official records.

Enter the starting date for the eighth week being logged (the 'Week of' date for this row).

Enter the number of hours spent in individual or triadic supervision during the eighth week.

Enter the number of hours spent in group supervision during the eighth week.

Enter the number of hours spent on clinical psychosocial diagnosis, assessment, and treatment (individual or group) during the eighth week.

Enter the number of hours spent providing individual or group psychotherapy or counseling during the eighth week.

Enter the number of hours spent on client‑centered advocacy, consultation, evaluation, research, workshops, trainings, or related direct client work during the eighth week.

Enter the total number of hours for the eighth week (the sum of the applicable category hours for that week).

Enter the supervisor's signature or printed name to verify and attest to the accuracy of the hours recorded for the eighth week.

Enter the calendar date that marks the beginning of the fifth week being reported.

Enter the total hours for the fifth week spent in individual or triadic supervision.

Enter the total hours for the fifth week spent in group supervision.

Enter the total hours for the fifth week spent on clinical psychosocial activities such as diagnosis, assessment, treatment, counseling, or related interventions.

Enter the total hours for the fifth week spent specifically in individual or group psychotherapy.

Enter the total hours for the fifth week spent on client-centered advocacy, consultation, evaluation, research, trainings, seminars, supervision, or direct client contact.

Enter the total number of hours for the fifth week (the sum of the applicable category columns for that week).

Enter the supervisor's printed name or electronic signature corresponding to the fifth week row.

Enter the calendar date that marks the start of the first reporting week (the 'Week of' date).

Enter the number of hours spent in individual or triadic supervision during the first week.

Enter the number of hours spent in group supervision during the first week.

Enter the hours spent on clinical psychosocial diagnosis, assessment, and treatment activities (including individual or group interventions) for the first week.

Enter the hours spent providing individual or group psychotherapy during the first week.

Enter the hours spent on client‑centered advocacy, consultation, evaluation, research, workshops, seminars, training sessions, and related activities for the first week.

Enter the total combined hours for the first week (the sum of applicable clinical, supervision, and other recorded hours).

Enter the supervisor's signature or printed name to verify and approve the hours recorded for the first week.

Enter the starting date for the fourth week being logged.

Enter the number of hours spent in individual or triadic supervision during the fourth week.

Enter the number of hours spent in group supervision during the fourth week.

Enter the number of hours spent on clinical psychosocial diagnosis, assessment, and treatment activities for the fourth week.

Enter the number of hours spent providing individual or group psychotherapy during the fourth week.

Enter the number of hours spent on client-centered advocacy, consultation, education, research, training, conferences, or supervisor contact in the fourth week.

Enter the total hours for the fourth week (the sum of the activity columns for that week).

Enter the supervising clinician's name or signature as verification for the hours recorded for the fourth week.

Enter the starting date for the ninth week (the 'Week of' date) corresponding to this row.

Enter the number of hours spent in individual or triadic supervision during the ninth week.

Enter the number of hours spent in group supervision during the ninth week.

Enter hours spent in clinical psychosocial assessment, diagnosis, treatment, or individual/group psychotherapy or counseling (column A) for the ninth week.

Enter hours spent in individual or group psychotherapy (column A1) during the ninth week.

Enter hours spent in client-centered advocacy, consultation, evaluation, research, workshops, seminars, trainings, or related activities (column B) for the ninth week.

Enter the total weekly hours for the ninth week (column C), typically the sum of clinical and client-centered activity hours.

Enter the supervisor's signature or printed name certifying and verifying the hours recorded for the ninth week.

Enter the starting date of the week being reported for this row.

Enter the number of hours spent in individual or triadic supervision during this week.

Enter the number of hours spent in group supervision during this week.

Enter the hours for clinical psychosocial diagnosis, assessment, and treatment (including related individual or group psychotherapy) performed this week.

Enter the number of hours spent providing individual or group psychotherapy during this week.

Enter the hours spent on client-centered advocacy, consultation, evaluation, research, seminars/workshops/training, conferences, and direct supervisor contact during this week.

Enter the total number of hours for this week (the sum of the applicable activity columns for this row).

Enter the supervisor's name or signature to verify and accept the hours recorded for this week.

Enter the starting date for the seventh week that this row represents.

Enter the number of hours of individual or triadic supervision received during the seventh week.

Enter the number of hours of group supervision received during the seventh week.

Enter the number of hours for any other type of supervision (as applicable) during the seventh week.

Enter the number of clinical or psychosocial service hours (diagnosis, assessment, treatment, counseling) for the seventh week.

Enter the number of individual or group psychotherapy hours provided during the seventh week.

Enter the total hours for the seventh week (sum of the applicable category columns).

Enter the supervisor's name or signature to confirm and authorize the hours recorded for the seventh week.

Enter the starting date for this week (the 'Week of' date) for the sixth row.

Enter the number of hours of individual or triadic supervision completed during this week.

Enter the number of hours of group supervision completed during this week.

Enter the number of hours spent on clinical psychosocial diagnosis, assessment and treatment (including individual or group counseling) during this week.

Enter the number of hours spent providing individual or group psychotherapy during this week.

Enter the number of hours spent on client-centered advocacy, consultation, evaluation, research, workshops, training sessions, conferences, or supervisor contact during this week.

Enter the total hours for this week (the sum of the applicable category hours for the sixth week).

Enter the supervisor's signature or printed name to verify and approve the hours recorded for this week.

Enter the supervisor's last (family) name as it should appear on official records.

Enter the full name of the work setting or employer where the supervised experience took place.

Enter the complete street address of the work setting, including number, street, city, and state.

Enter the starting date of the tenth week being reported.

Enter the number of hours spent in individual or triadic supervision during the tenth week.

Enter the number of hours spent in group supervision during the tenth week.

Enter the number of hours spent on clinical psychosocial diagnosis, assessment, and treatment (line A) during the tenth week.

Enter the number of hours spent on individual or group psychotherapy (sub‑category A1) during the tenth week.

Enter the number of hours spent on client-centered advocacy, consultation, evaluation, trainings, research, or related activities (line B) during the tenth week.

Enter the total number of hours for the tenth week (line C) as required by the form.

Enter the supervisor's signature or printed name to verify and approve the hours recorded for the tenth week.

Enter the starting date for the third week's log (the 'Week of' date).

Enter the number of hours spent in individual or triadic supervision during the third week.

Enter the number of hours spent in group supervision during the third week.

Enter the number of hours for clinical psychosocial diagnosis, assessment, and treatment (category A) during the third week.

Enter the number of hours spent providing individual or group psychotherapy (category A1) during the third week.

Enter the number of hours for client-centered advocacy, consultation, research, training, or related activities (category B) during the third week.

Enter the total number of hours for the third week (the sum used for the 'Total Hours Per Week' column).

Enter the supervisor's name or signature verifying the hours recorded for the third week.

Enter the total hours for the week spent in individual or triadic supervision.

Enter the total hours for the week spent in group supervision.

Enter the total hours for the week spent on clinical psychosocial activities (diagnosis, assessment, treatment, individual or group psychotherapy/counseling).

Enter the total hours for the week spent providing individual or group psychotherapy (A1 subcategory).

Enter the total hours for the week spent on client-centered advocacy, consultation, evaluation, research, workshops, seminars, training sessions, conferences, or direct supervisory contact.

Enter the total weekly hours that combine categories A and B as shown in box C.

Enter the supervisor's signature or typed name authorizing the reported weekly totals.

Enter the calendar year that this weekly experience hours log covers (for example, 2025).