One Form, Filed by the Supervisor
One agency runs this across all three tracks: the New York State Education Department (NYSED) Office of the Professions. Form 4B is the document that verifies supervised experience once it is finished, and the LCSW, LMHC, and LMFT tracks each use their own version of it.
Form 4B is a one-time cumulative verification: each supervisor completes it once, summarizing the hours accrued under them. On the LCSW track it sits on top of a running record: the form's instructions say to "use the psychotherapy log to document your hours of practice and supervision," a log "completed by you and your supervisor," with "all pages of the log" retained by the supervisor in case the State Board requests clarification. NYSED's Form 4B page says the log should be completed weekly. The LMHC and LMFT versions of Form 4B do not mention a log.
Three Tracks, Three Files
Each track has its own file, its own title, and its own revision date on the NYSED site.
| Track | File | Revision | Title |
|---|---|---|---|
| LCSW | lcsw4b.pdf | Rev. 10/24 | Certification of Experience for Licensed Clinical Social Worker |
| LMHC | mhc4b.pdf | Rev. 10/24 | Certification of Supervised Experience |
| LMFT | mft4b.pdf | Revised 9/20 | Certification of Supervised Experience |
The LMFT version carries an older revision date than the LCSW and LMHC versions. Pull the current file from the application-forms page for your track before you hand it to a supervisor, rather than reusing a copy someone else already has.
Only the Supervisor Files It
Every version of Form 4B carries the same instruction: the supervisor submits it, directly, to the Office of the Professions. "The Office of the Professions will not accept this form if submitted by the applicant."
One Form 4B covers one supervisor. If your supervised experience ran under more than one supervisor, each of them files their own copy, reporting only the hours they personally supervised. There is no combined form for multiple supervisors.
For the LCSW track, if the supervisor has died before filing, a licensed professional colleague may complete Form 4B in their place, providing the supervisor's qualifications, the dates and frequency of the supervision, and an attestation to the accuracy of the applicant's supervised experience.
Section I, Appendix A, Then It Leaves Your Hands
Your part of Form 4B is Section I. You complete it and send the entire form, along with a copy of Appendix A, to your supervisor. From that point, the form is theirs: they complete their section, sign and date it, and mail the whole thing directly to the Office of the Professions.
NYSED publishes no filing deadline for Form 4B on the pages reviewed for this guide.
What Form 4B Confirms, Per Track
| Track | What the form verifies | Citation |
|---|---|---|
| LCSW | 2,000 client contact hours and 100 supervision hours, over 36 to 72 months | Educ. Law 7704(2)(c); 8 NYCRR 74.3(a), 74.6(c)(1)(v) |
| LMHC | 3,000 hours, including at least 1,500 direct client contact hours | 8 NYCRR 79-9.3(a) |
| LMFT | 1,500 hours, all of it direct client contact | 8 NYCRR 79-10.3(a) |
The LMHC total is not 3,000 hours on top of 1,500 direct hours; the 1,500 is part of the 3,000, and the rest may be indirect activity. The LMFT total has no indirect category at all. Every hour a supervisor reports on an LMFT Form 4B is direct client contact.
The Supervisor Keeps the Records Form 4B Draws From
For the LCSW track, the supervisor "shall be responsible for maintaining records of the client contact hours in diagnosis, psychotherapy and assessment-based treatment planning and supervision hours," and must produce them to the Department on request (8 NYCRR 74.6(e)).
For the LMHC track, the supervisor "shall submit verification of the supervised experience on forms acceptable to the department" and must maintain that documentation as well (8 NYCRR 79-9.3(e)). In both tracks, the record Form 4B eventually reports comes from the supervisor's files, not the applicant's.
Two Supervisors, Two Forms
Take an LCSW candidate who completes the required experience under two supervisors over a 36-month period. The first supervisor oversees the first 20 months and later files a Form 4B reporting 1,100 client contact hours and 55 supervision hours. The second supervisor oversees the remaining 16 months and files a separate Form 4B reporting 900 client contact hours and 45 supervision hours.
Add the two forms together: 1,100 plus 900 is 2,000 client contact hours, and 55 plus 45 is 100 supervision hours, both landing at the thresholds 8 NYCRR 74.3(a) and 74.6(c)(1)(v) set. Twenty months plus 16 months is the full 36-month minimum. Neither form by itself proves the requirement is met; the two together do.
Keep Your Own Numbers While a Supervisor Keeps Theirs
Form 4B is filed from your supervisor's records, not yours. If a supervisor changes jobs, retires, or simply keeps informal notes, their count and your count can drift apart long before either of you notices. Keeping your own per-supervisor totals and dates from day one is how you check what a supervisor is about to attest to, while there is still time to reconcile it with them, rather than after the form has already been mailed.
Common Mistakes With Form 4B
These are common errors around Form 4B, all of them preventable with records kept along the way.
Assuming one Form 4B covers a whole experience period
Each supervisor files their own copy, reporting only the hours they personally supervised. There is no combined form for multiple supervisors.
Submitting the form yourself
The Office of the Professions will not accept Form 4B if submitted by the applicant, on any of the three tracks.
Sending Section I to a supervisor without Appendix A
The applicant's job is to send the entire form and a copy of Appendix A together, not Section I on its own.
Treating the LMHC 1,500 direct hours as extra hours
The 1,500 direct client contact hours are part of the 3,000-hour total, not additional to it (8 NYCRR 79-9.3(a)).
Using an outdated LMFT Form 4B
The LMFT file carries a Revised 9/20 date, older than the LCSW and LMHC versions. Pull the current copy from the application-forms page before use.
Waiting for your own records instead of keeping them
The supervisor's records are what Form 4B reports. Keeping your own per-supervisor totals is how you catch a mismatch before the form is mailed, not after.
Track What You'll Need Before the Form Gets Filed
Nobody but your supervisor can file Form 4B, and they'll do it from their own records once your time together is over. Keeping your own numbers from day one is how you check their totals before their form becomes the only copy that exists.
- ✓Log hours by week
- ✓Running totals kept per supervisor
- ✓Running totals by category
- ✓An export history
Built for pre-licensed clinicians.
Related New York Guides
New York LCSW Requirements
The 2,000-hour client contact requirement and the 36 to 72 month window Form 4B verifies.
New York LMHC Requirements
The 3,000-hour requirement, including the 1,500 direct client contact hours.
LMSW to LCSW in New York
The clinical supervision plan pathway an LMSW follows toward the LCSW license.
The LMHC Limited Permit
How the limited permit works while LMHC hours and supervision accrue.
How to Become an LCSW in New York
The full path from MSW to license, including the LMSW step and the exam.
All New York Guides
Every New York licensure guide across the LCSW, LMHC, and LMFT tracks.
FAQ: NYSED Form 4B
What is NYSED Form 4B?▾
Form 4B is the form New York uses to verify supervised experience for the LCSW, LMHC, and LMFT tracks. Each track has its own version of the form, but all three work the same way: each supervisor fills it out once and reports the hours accrued under them directly to the Office of the Professions. It is a one-time, cumulative attestation per supervisor; on the LCSW track, the running record is the separate psychotherapy log the supervisor retains.
Who submits Form 4B in New York?▾
The supervisor submits it, directly to the Office of the Professions. The instruction on every version of the form is the same: it will not be accepted if submitted by the applicant. The applicant's role is limited to completing Section I and sending the form, along with a copy of Appendix A, to the supervisor.
What is the difference between Form 4B for LCSW, LMHC, and LMFT?▾
Each track uses its own file with its own revision date. The LCSW version, lcsw4b.pdf, is titled Certification of Experience for Licensed Clinical Social Worker, Rev. 10/24. The LMHC version, mhc4b.pdf, is titled Certification of Supervised Experience, also Rev. 10/24. The LMFT version, mft4b.pdf, carries an older revision, 9/20. All three follow the same rule: the supervisor files it, not the applicant.
Do I need a separate Form 4B for each supervisor?▾
Yes. One Form 4B covers one supervisor's portion of your supervised experience. If you worked under two supervisors, each of them completes and files their own copy, reporting only the hours they personally supervised. There is no single combined form for multiple supervisors.
Does New York have a weekly log form for supervised hours?▾
For the LCSW track, yes: the Form 4B instructions say to use the psychotherapy log to document hours of practice and supervision. It is completed by you and your supervisor, NYSED says it should be completed weekly, and the supervisor retains every page in case the State Board requests clarification. The LMHC and LMFT Form 4B do not mention a log. On every track, Form 4B itself is the verification NYSED receives.
What happens if my LCSW supervisor has died before filing Form 4B?▾
For the LCSW track, a licensed professional colleague may complete Form 4B on the deceased supervisor's behalf, providing the supervisor's qualifications, the dates and frequency of supervision, and an attestation to the accuracy of the applicant's supervised experience.
Requirements verified against Education Law Article 154 and Article 163, and 8 NYCRR Part 74 and Subparts 79-9 and 79-10, as published by the New York State Education Department (NYSED) Office of the Professions, checked September 2026. Statutes and regulations can change. Always confirm current requirements at op.nysed.gov before making decisions about your licensure path. This guide is for informational purposes only and does not constitute legal or professional advice.