North Carolina Psychology Board

Instructions/Information for Making Application
Based on Mobility Credential
See G.S. § 90-270.13(a1) and 21 NCAC 54 .1701 (b) & (c)

Standard forms are hyper-linked within the following instructions. PLEASE NOTE: While the forms are INTERACTIVE (information may be typed directly into text fields) Adobe Reader WILL NOT allow data to be saved upon exit of the program. The applicant is strongly advised to print copies before exiting out of forms. Following receipt of the application, the Board may, in some cases, require that additional documentation be submitted. The applicant will be contacted by Board staff if any additional forms or information are needed.

G.S. 90-270.139 requires persons to make application for licensure to the Board within 30 days of offering to practice or undertaking the practice of psychology in North Carolina unless individuals are exempt from licensure. To make application the following materials must be submitted together and received in the Board office within 30 days of offering to practice or undertaking the practice of psychology in North Carolina:

• The application form
• The supervision contract form
• The $100 application fee
• The fingerprint card for background checks (As of 11/01/16)
• The $38 background check fee
• Authority for release of information form

Once these items are received, the Board we will process the application and email the applicant to let him/her know what additional applications items are required.  The applicant has up to 90 days to submit the rest of his/her remaining application materials after submission of these forms.

1. Application for Licensure Based on Mobility Credential
   [NOTE: The Board reviews an application for licensure to determine an individual’s eligibility for examination. If approved for examination, the applicant will be sent further materials regarding registering for the examination(s).]
2. The North Carolina Practice Act
3. Supervision Contract Form
4. Fingerprint cards and Instructions(Starting 11/01/2016)
5. Reference Form
6. Application for Health Services Provider Psychologist (HSP-P) Based on Mobility Credential
7. Documentation of Organized Health Services Training Program (HSP Form #1)
8. Supervisor Form

1. APPLICATION FOR LICENSURE BASED ON MOBILITY CREDENTIAL
   1. Pursuant to G.S. § 90-270.5, persons who are qualified by education to practice psychology in North Carolina must make application for licensure to the Board within 30 days of offering to practice or undertaking the practice of psychology in North Carolina. Persons who fail to do so may not subsequently practice or offer to practice psychology without first becoming licensed. To make application, the following materials are required to be received in the Board’s office:
      1. completed, signed, application form. The Board suggests that you keep a copy of the completed application form for your records.
      2. completed, signed, Supervision Contract Form (see Item #3).
      3. non-refundable $100.00 application fee. Make checks or money orders payable to the North Carolina Psychology Board. A $20.00 fee will be charged for any returned bank item. 
      4. Fingerprint Card, Authority for Release Form, $38 background check fee. 
   2. Additional information, including but not limited to the following, will be required for some applicants.
      1. If ever licensed, or having applied for a license, in another jurisdiction, arrange to have the jurisdiction(s) write directly to the NC Psychology Board verifying and reporting on the status of licensure (or application for licensure), including any disciplinary action which is pending or has been taken.
      2. If you hold a Certificate of Professional Qualification (CPQ) from the Association of State and Provincial Psychology Boards (ASPPB), arrange to have ASPPB send written verification of your CPQ status directly to the NC Psychology Board. 
      3. If you are a registrant with the National Register of Health Service Providers in Psychology (NRHSPP), arrange to have NRHSPP send written verification of your registration directly to the NC Psychology Board.
      4. If you hold a diploma from the American Board of Professional Psychology, arrange to have ABPP write directly to the NC Psychology Board to verify your ABPP status.
      5. If you have been convicted of, or entered a plea of guilty or nolo contendere to any felony or misdemeanor other than a minor traffic violation, include a copy of any court document which indicates final disposition of the case.
      6. If you are, or have been, licensed or certified in another field of work; or made application for licensure or certification, arrange to have the applicable source (e.g., board, association, agency) write directly to the NC Psychology Board verifying and reporting on the status of licensure or application, including any disciplinary action which is pending or has been taken.
   3. An application must contain all requested information to be complete, including supervisor and reference forms, transcripts, and any additional information referenced in (c) above. An incomplete application is active for three months from the date of application. At the end of such time if still incomplete, the application becomes void, the applicant is deemed to have discontinued the application process, and must totally reapply. Consequently, the applicant must terminate the practice of psychology, unless otherwise exempt under the Practice Act, and must not practice psychology in North Carolina without first becoming licensed.
   4. It is the applicant’s responsibility to make sure that deadlines are met. Generally, if an application is completed (i.e., all requested application material is received in the Board office) no later than the last working day of the current month, the application will be reviewed by the last working day of the following month. However, in some circumstances, an application file must be reviewed by the full Board. Board meeting and deadline dates are available on the Board’s website by selecting the “Important Dates” link on the side bar, or may be obtained by contacting the Board office.
   5. To confirm receipt of documents by the Board, send by certified mail, return receipt requested.
   6. No application material may be faxed or submitted electronically to the Board.
   7. North Carolina residence is not required to apply for licensure.

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2. NORTH CAROLINA PSYCHOLOGY PRACTICE ACT
   The North Carolina Psychology Practice Act governs all of the practice of psychology in this state. The Board is given its authority under this statute, enacted by the state legislature, to regulate the practice of psychology. Many of the application forms refer to specific laws and rules that are found in this document.
   

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3. SUPERVISION CONTRACT FORM
   All applicants are required to have an accurate, up-to-date Supervision Contract Form on file with the Board at all times. This is a requirement regardless of the employment setting or activities in which the applicant may, or may not, currently be engaged (e.g., unemployed, practicing out-of-state, working in another field, etc.). A Supervision Contract Form documents either that supervision is required and being received, OR that supervision is not required.

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4. FINGERPRINT CARDS AND INSTRUCTIONS                         The Board requires applicants to consent to criminal history record background checks.  Please click the Fingerprint Card link for more information about this process.                                                                                        
   
5. REFERENCE FORM (Item #17 on the application form)
   1. Print a copy of the Reference Form for each of the required three professional (not personal) references who are familiar with your current work. At least one reference must be from a doctoral level psychologist, and two references may be from other professions. These references must have knowledge of the applicant’s professional skills and competencies within the past year. 
   2. Reference Forms must be completed within 90 days prior to the application date to ensure they are current and up-to-date. competencies within the past year.
   3. Type or print the name of the reference and your name where indicated.
   4. Send a form to each reference (or refer him/her to where the form is found on the Board website) with instructions to return the completed form to you, the applicant, in a sealed envelope with the reference’s signature over the seal. Forms submitted to the Board office without the reference’s signature over the seal will NOT be accepted.
   5. Individuals completing Supervisor forms CANNOT also serve as references.

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6. APPLICATION FOR HEALTH SERVICES PROVIDER PSYCHOLOGIST (HSP-P) BASED ON MOBILITY CREDENTIAL
   This application is required to be completed and submitted if you are becoming licensed to render health services in North Carolina. HSP certification is in addition to licensure and is mandatory for permanently licensed psychologists who render health services in North Carolina.

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7. DOCUMENTATION OF ORGANIZED HEALTH SERVICES TRAINING PROGRAM (HSP FORM #1)
   
   1. This form is required to be completed and submitted only if you are applying for HSP-P certification as a CPQ holder and you are not having materials that are banked with ASPPB which document the required supervised experience in health services provider activities sent directly to the Board from ASPPB. This form is not required if you are applying for HSP-P as a registrant in the National Register or as an ABPP diplomate.
   2. On the Documentation of Organized Health Services Training Program (HSP FORM #1), type or print your name and the training site name and address where indicated.
   3. Send a copy of the form, as applicable, to each direct supervisor who is listed on your HSP-P application form under Item 2 (or refer him/her to where the form is found on the Board website).
   4. If appropriate, send cover letters informing the supervisor(s) of the date on which you need to receive the form back, reminding them of the approximate dates, hours, and locations of the supervised experience. To assist your supervisor in reporting the number of hours engaged in the practice of psychology and in health services, you may wish to refer him/her to the question, “What is the difference between health services and the practice of psychology?” under the “Frequently Asked Questions” link on the Board’s website.
   5. If you can no longer locate a supervisor or if a supervisor is deceased, you must arrange to have the Supervisor form completed by someone else at the institution, or by someone who was at the institution when you were supervised, who can verify the experience; or have another state licensing board forward documentation of supervision from your file in their office; and you must provide a written explanation regarding the unavailability of the direct supervisor. If no one can verify the listed supervised experience, you must provide a written explanation. Be aware that such explanations do not assure acceptance of a waiver of this requirement.

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8. SUPERVISOR FORM (Documentation of supervised experience in health services that was not in an organized training program)
   1. This form is required to be completed and submitted only if you are applying for HSP-P certification as a CPQ holder and you are not having materials that are banked with ASPPB which document the required supervised experience in health services provider activities sent directly to the Board from ASPPB. This form is not required if you are applying for HSP-P as a registrant in the National Register or as an ABPP diplomate.
   2. On the form, type or print the name of the supervisor and your name where indicated.
   3. Send a copy of the form, as applicable, to each direct supervisor who is listed on your HSP-P application form under Item 3 (or refer him/her to where the form is found on the Board website).
   4. Refer to 6. (d) and (e) above for further instructions.
      

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9. TRANSCRIPTS
   Arrange to have your transcript sent directly to the Board from the institution of higher education from which you received your doctoral degree, or if applicable, from the Association of State and Provincial Psychology Boards, National Register of Health Services Providers in Psychology, or American Board of Professional Psychology.

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10. EXAMINATIONS
    In addition to the following, see examination requirements in 21 NCAC 54 .1900 (printed under Selected Board Rules at the end of the board-produced copy of the NC Psychology Practice Act).
    1. National Examination. The Examination for Professional Practice in Psychology (EPPP) is not required for applicant's whose credentials are approved under mobility application provisions.
    2. State Examination. The Board-developed State Examination assesses the applicant's knowledge of the North Carolina Practice Act, selected rules of the Board covering such topics as education and supervision, and other legal requirements, and the APA Ethics Code. The State Examination is currently a 50-item, multiple choice examination. Effective June, 2006, the State Examination will be administered on computer at PSI testing centers. Upon payment of the $200.00 State Examination fee to the NC Psychology Board, an applicant who has been approved by the Board for examination will call PSI to schedule the examination for his or her chosen location and date.

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11. POST-DOCTORAL EXPERIENCE EXPLAINED
    For applicants applying on the basis of a CPQ, post-doctoral supervised experience may commence any time after the doctoral degree is awarded. However, applicants who met all requirements [i.e., both substantive (including dissertation) and administrative requirements] for their doctorate prior to the degree’s ceremonial awarding may commence their post-doctoral experience anytime after the earlier "met all requirements" date. For those who started their experience early, if a "met all requirements" date is clearly noted on the transcript, no further documentation is required. However, if this date is not on the transcript, a VERIFICATION OF DEGREE FORM must be completed and submitted.

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IF YOU DO NOT UNDERSTAND ANY PART OF THE APPLICATION PROCESS, PLEASE EMAIL THE BOARD OFFICE. FAILURE TO COMPLETE THE PROCESS BY ESTABLISHED DEADLINES AND IN THE REQUIRED FORMAT WILL CAUSE A DELAY IN APPLICATION REVIEW AND MAY AFFECT YOUR PRIVILEGE TO PRACTICE PSYCHOLOGY WITHOUT A LICENSE AS AN APPLICANT.