Free 27522.FH11 - Indiana

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APPLICATION FOR LICENSURE TO PRACTICE PSYCHOLOGY IN INDIANA
State Form 27522 (R10 / 10-07) Approved by State Board of Accounts, 2007

STATE PSYCHOLOGY BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2051 E-mail: [email protected]

* Your Social Security number is requested by this agency in accordance with IC 4-1-8-1, and it is mandatory that it be given. FOR AGENCY USE ONLY
Date received (month, day, year) Decision Initials

PSYCHOLOGY LICENSE Application fee Date fee paid (month, day, year) Receipt number License number License issuance date (month, day, year)

TEMPORARY PERMIT Application fee Date fee paid (month, day, year) Receipt number Permit number Permit issuance date (month, day, year)

APPLICANT
Attach two (2) passport type quality photographs of yourself taken within the last eight weeks.

DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Name (last, first, middle, maiden) Home address (number and street or rural route) Telephone number (daytime) Date of birth (month, day, year) Social Security number* City Place of birth E-mail address State ZIP code

(

)

Are you applying for licensure by: Do you desire a temporary license?

Examination

Endorsement

Yes

No

GRADUATE EDUCATION (Doctoral)
Name of school Street address (number and street, city, state, and ZIP code) Number of hours required for degree (excluding dissertation hours)? Which were the hours? Semester Quarter Department Dates attended (month, day, year) APA approved at the time of graduation? Yes No Title of program Degree earned

PREDOCTORAL INTERNSHIP
Was an Internship required for graduation? Yes Name of internship program Address of internship program (number and street, city, state and ZIP code) APA approved at the time of completion? Yes Inclusive dates of internship (month, day, year) Director of internship training No APPIC approved at the time of completion? Yes Total hours worked No No

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POST DOCTORAL EDUCATION
Name of school Address (number and street, city, state, and ZIP code) Department Title of program Dates attended (month, day, year)

POST DOCTORAL INTERNSHIP / FELLOWSHIP
Name of Internship/Fellowship Address of Internship/Fellowship (number and street, city, state and ZIP code) Inclusive dates of Internship/Fellowship (month, day, year) Name of Supervising Psychologist Total hours worked

PROFESSIONAL IDENTITY BASED UPON DOCTORAL TRAINING
(Check only one or attach explanation)

Clinical Psychology Counseling Psychology Experimental Developmental

Organizational / Industrial School Social Other (specify) CLAIMED AREAS OF COMPETENCE

Do you hold, or have you ever held, a license, certificate, registration or permit to practice any regulated health occupation? Yes No

List all states, including Indiana, in which you have been licensed to practice any regulated health occupation: TYPE OF LICENSE, CERTIFICATE, REGISTRATION OR PERMIT STATE NUMBER DATE ISSUED CURRENT STATUS

Have you previously taken the Examination for the Professional Practice of Psychology (EPPP)? If "Yes", how many times? Date of most recent test (month,year) Yes No Where taken (state, country) If "Yes", when was the application filed (month, day, year)? If "Yes", state the Certificate / License number

Have you previously filed an application for licensure as a psychologist in the State of Indiana? Yes No Do you currently hold, or have you ever held, a Basic Certificate or Limited License to practice psychology in Indiana? Yes No Describe the nature of the practice of psychology in which you intend to engage:

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WE MUST RECEIVE WRITTEN DOCUMENTATION FROM YOUR CURRENT OR MOST RECENT EMPLOYER VERIFYING THE FOLLOWING INFORMATION REGARDING YOUR CURRENT OR MOST RECENT EMPLOYMENT ONLY.

List all places of professional employment, including self employment, since obtaining your doctoral degree (past ten years only). Begin with your current position and indicate your current title. DATES (month, day, year) POSITION / TITLE Current RESPONSIBILITIES HOURS / WEEK SUPERVISOR

NAME AND ADDRESS OF EMPLOYER

Current Employment

Past Employment

Past

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COURSEWORK INFORMATION
List the course number and course title of the graduate coursework you have completed in the required content areas as they appear on your transcript. If the course titles as stated on your transcript do not clearly reflect the required content areas, you may be requested to provide additional supporting documentation such as course syllabus, term papers, etc. You may use the same course for more than one content area. Also, each content area may contain more than one course.

NAME OF EDUCATIONAL INSTITUTION

BIOLOGICAL BASES OF BEHAVIOR COURSE NUMBER COURSE TITLE

CREDIT HOURS

Semester Quarter

NAME OF EDUCATIONAL INSTITUTION

COGNITIVE-AFFECTIVE BASES OF BEHAVIOR COURSE NUMBER COURSE TITLE

CREDIT HOURS

Semester Quarter

NAME OF EDUCATIONAL INSTITUTION

SOCIAL BASES OF BEHAVIOR COURSE NUMBER COURSE TITLE

CREDIT HOURS

Semester Quarter

NAME OF EDUCATIONAL INSTITUTION

INDIVIDUAL DIFFERENCES COURSE NUMBER COURSE TITLE

CREDIT HOURS

Semester Quarter

If your answer is "Yes" to any of the following, explain fully in a notarized affidavit, including all related details. Describe the event including location, date, and disposition. If malpractice, provide name of plaintiff. Falsification of any of the following is grounds for permanent revocation of a certificate or permit issued pursuant to this application. 1. Has disciplinary action ever been taken regarding any health license, Yes No certificate, registration or permit that you hold or have held? 2. Have you ever been denied a license, certificate, registration or permit to practice psychology, or any regulated health occupation in any state or country (including Indiana). 3. Are you now, or have you ever been treated for drug or alcohol abuse? 4. Have you ever been charged with a crime related to drug or alcohol use? 5. Have you ever been convicted of, pled guilty or nolo contendere to: A. A violation of any Federal,State or local law relating to the use, manufacturing, distribution or dispensing of controlled substances or drug addiction? B. Any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines.) 6. Have you ever been denied staff membership or privileges in any hospital or health care facility or had such membership or privileges revoked, suspended or subjected to any restrictions, probation or other type of discipline or limitations? 7. Have you ever been admonished, censured, reprimanded or requested to withdraw, resign or retire from any hospital or health care facility in which you have trained, held staff membership or privileges or acted as a consultant? 8. Have you ever had a malpractice judgment against you or settled any malpractice action? Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No

APPLICATION AFFIRMATION I hereby swear or affirm under the penalties of perjury that the statements made in this application are true, complete and correct.
Name of applicant (Please print or type - first, middle initial, last) Signature of applicant Date (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request, and direct any person, firm, officer, corporation, association, organization, or institution to release to the Professional Licensing Agency, or the State Psychology Board, any files, documents, records or other information pertaining to the undersigned requested by the Agency, or the Board, or any of their authorized representatives, in connection with processing my application for licensure. I hereby release the aforementioned persons, firms, corporations, associations, organizations, persons and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency, or the State Psychology Board, to disclose to the aforementioned organizations, persons and institutions any information which is material to my application, and I hereby specifically release the Agency, and the Board, from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION I hereby swear and affirm that I have read the above statements and agree to same.
Signature of applicant Date (month, day, year)

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