Free 20231.FH11 - Indiana

Reset a Form

APPLICATION FOR ENDORSEMENT AS A HEALTH SERVICE PROVIDER IN PSYCHOLOGY (HSPP)
State Form 20231 (R12 / 7-07) Approved by State Board of Accounts, 2006

INDIANA 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 OFFICE USE ONLY
Date reviewed (month, day, year) Fee License number Date fee paid (month, day, year) Decision Receipt number Initials HSPP endorsement issuance date (month, day, year)

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) City Place of birth Social Security number * State E-mail address ZIP code

(

)

Name of school Street address (number and street, city, state, and ZIP code) Dates attended (month, day, year)

DOCTORAL EDUCATION
Department Title of program

Degree earned

APA approved at time of graduation?

Yes TRAINING IN AN ORGANIZED HEALTH SERVICE TRAINING PROGRAM (PRE-DOCTORIAL INTERNSHIP)
A. Name and address of internship program

No

B. APA approved at the time of completion?

C. APPIC approved at the time of completion?

Yes
D. Inclusive dates of internship (month, day, year) FROM:

No
TO:

Yes
Total hours worked

No

E. Name of supervising psychologists and their certification - licensure status

Name Director of Training Other supervising Psychologists

Degree

State Where Certified - Licensed

F. Number of interns in program at the time you were in the program

G. Approximate number of hours of direct supervision per week (individual, not group supervision)

H. Number of seminar hours per week

Are you currently, or have you ever been listed in the National Register of Health Service Providers in Psychology? Do you currently, or have you ever possessed a Certificate of Professional Qualification (CPQ) from the ASPPB?

If yes, please state the year of your first listing:

Yes Yes

No
If yes, please state the year it was issued to you:

No

EXPERIENCE IN A SUPERVISED HEALTH SERVICE SETTING (Post-Doctoral Work Experience)
Attach additional sheets for multiple settings Name of facility Address (number and street, city, state, and ZIP code) Your title Inclusive dates (month, day, year) FROM: TO: Number of hours you engaged in direct patient contact Number of hours per week of direct face-to-face supervision (individual, not group) you received. Number of hours you supervised others. Number of hours you engaged in teaching. If you supervised others, were they: Name of supervisor Supervisors degree Number of hours of supervised experience

Psychology graduate students

Other (describe)

Number of hours you engaged in research.

If your answer is Yes to any of the following, explain 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 an endorsement issued pursuant to this application. 1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held? 2. Have you ever been denied a license, certificate, registration, permit, or endorsement 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 convicted of, pled guilty or nolo contendre 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.) 5. 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? 6. 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? 7. 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.
Signature of applicant Date signed (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 any files, documents, records or other information, pertaining to the undersigned, requested by the Agency or any of its authorized representatives in connection with processing my application for endorsement. I hereby release the aforementioned persons, firms, officers, corporations, associations, organization, persons and institutions from any liability with regard to such inspection or furnishing of such information. I further authorize the Professional Licensing Agency, or the Indiana State Psychology Board to disclose to the aforementioned organization, persons and institutions any information which is material to my application, and I hereby specifically release the Agency and 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 or affirm that I have read the above statements and agree to the same.
Signature of applicant Date signed (month, day, year)

YOU MUST COMPLETE FORM A AND B (attached)

ENDORSEMENT AS A HEALTH SERVICE PROVIDER IN PSYCHOLOGY / VERIFICATION OF EXPERIENCE IN AN ORGANIZED HEALTH SERVICE TRAINING PROGRAM (Internship)
Part of State Form 20231 (R12 / 7-07) Approved by State Board of Accounts, 2006

INDIANA STATE PSYCHOLOGY BOARD INSTRUCTIONS - ALL APPLICANTS: 1. 2. 3. 4. 5.

FORM A

Complete the top section. Make copies and send this form to the Director of Training of your experience in an organized health service training program (internship). Direct the individual(s) to send this form directly to the Professional Licensing Agency. If the Director of Training is not available, another psychologist associated with the internship may complete the form. If a psychologist is not available, you must provide a written explanation to the Board.

1. Name (last, first, middle, maiden) 2. Home address (number and street or rural route) 3. License number City Date of issuance (month, day, year) State ZIP code

Date of birth (month, day, year)

I authorize Professional Licensing Agency with the following information.
Signature of applicant

to furnish the Indiana State Psychology Board /
Date of signed (month, day, year)

TO:
Please verify that has received acceptable, supervised experience in an organized health service program (internship) by providing the following information.
1. Name and address of the agency providing the training program

2. Your name and current address

3. Your title at the agency at the time the applicant was in the program 4. What role did you play in the internship? 5. Did you directly supervise the applicant? If No, what was your relationship to the applicant?

Yes
6. Type of patient / client population

No

7. When did the applicant receive training in your program / internship? (please provide exact beginning and ending dates) FROM: a. Was the internship APA approved at the time of completion? TO:

Yes Yes

No No

b. Was the internship APPIC approved at the time of completion? c. Number of hours per week applicant worked in this setting d. Number of hours per week applicant received individual, not group, supervision e. Duration of the supervision (number of weeks or months) f. Total number of hours the applicant worked in this setting 8. Number of interns in the program when the applicant was in the program.

See Reverse Side

9. NAME AND DEGREES OF SUPERVISING PSYCHOLOGISTS Name Degree (at the time the applicant was in the program) State Where Certified / Licensed

10. Please give a brief description of the applicants internship experience

11. Was the internship satisfactorily completed? If No, please attach an explanation. 12. At the time of supervision A. Were you licensed or certified in Indiana? B. If you were licensed or certified in Indiana, were you endorsed as a health service provider in psychology? If you were not licensed or certified in Indiana and HSPP, or were not listed in the National Register, has your resume been attached?

Yes

No

Yes Yes Yes

No No No

VERIFICATION FORM AFFIRMATION

I hereby swear or affirm, under the penalty of perjury, that the statements made in this verification are true, complete and correct.
Signature Date signed (month, day, year)

Please respond as soon as possible so that the applicants endorsement request may be completed without delay. Please send all responses to: INDIANA STATE PSYCHOLOGY BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Thank you for your assistance in this matter.

ENDORSEMENT AS A HEALTH SERVICE PROVIDER IN PSYCHOLOGY / VERIFICATION OF EXPERIENCE IN AN ORGANIZED HEALTH SERVICE TRAINING PROGRAM (Post Degree)
Part of State Form 20231 (R12 / 7-07) Approved by State Board of Accounts, 2006

INDIANA STATE PSYCHOLOGY BOARD

FORM B

INSTRUCTIONS - ALL APPLICANTS: 1. Complete the top section. 2. Make copies and send this form to each individual who supervised your experience in a health service setting (post-degree / work experience). 3. Direct the individual(s) to send this form directly the Professional Licensing Agency.
1. Name (last, first, middle, maiden) 2. Home address (number and street or rural route) 3. License number City Date of issuance (month, day, year) State ZIP code

Date of birth (month, day, year)

I authorize Licensing Agency with the following information.
Signature of applicant

to furnish the Indiana State Psychology Board / Professional
Date of signed (month, day, year)

TO:
Please verify that has received acceptable, supervised experience in an organized health service setting (post-degree work experience) by providing the following information.
1. Name and address of the facility in which the experience was obtained

2. Your name and current address

3. Your title in the health service setting during the time you supervised the applicant 4. Type of patient / client population

5. INCLUSIVE DATES AND NUMBER OF HOURS PER WEEK THE APPLICANT WORKED IN THIS SETTING Dates (month, day, year)

Hours

a. Number of hours per week you directly supervised applicant (individual, not group, supervision) b. When did you supervise the applicant? (provide exact beginning and ending dates) c. Number of hours of experience completed by the applicant while under your supervision d. Number of hours of direct patient contact by the applicant while under your supervision

See Reverse Side

6. Briefly describe the nature of the applicants work

7. Was the supervised experience satisfactorily completed by the applicant? If No, please attach an explanation. 8. At the time of supervision: A. Were you licensed or certified in Indiana? B. If you were licensed or certified in Indiana, were you endorsed as a health service provider in psychology? If you were not licensed or certified in Indiana and HSPP, or were not listed in the National Register, has your resume been attached?

Yes

No

Yes Yes Yes

No No No

VERIFICATION FORM AFFIRMATION

I hereby swear or affirm, under the penalty of perjury, that the statements made in this verification are true, complete and correct.
Signature of supervisor Printed name of supervisor Date signed (month, day, year)

Please respond as soon as possible so that the applicants endorsement request may be completed without delay. Please send all responses to: INDIANA STATE PSYCHOLOGY BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Thank you for your assistance in this matter.