North Carolina Psychology Board

 Instructions/Information for Making Application for Reinstatement of Licensure

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.

1. Application for Reinstatement of Licensure Form
2. The North Carolina Practice Act
3. Supervision Contract Form
4. Fingerprint Cards and Instructions (Starting 11/01/2016)
5. Reference Form
6. Supervisor Form
7. Transmittal Form
8. Health Services Provider (HSP) Application Form

1. APPLICATION FOR REINSTATEMENT OF LICENSURE FORM
   1.  To make application, the following materials are required to be received in the Board’s office:
      1. completed, signed, application for reinstatement of licensure form. Under Item #18, only list experience to cover the current time back through the date on which your license was suspended due to non-renewal or voluntarily relinquished with the Board’s consent.
      2. completed, signed, Supervision Contract Form (see Item #3).
      3. Fingerprint Card, Authority for Release Form, $38 background check fee. 
      4. documentation to having completed a minimum of 24 continuing education hours as specified in 21 NCAC 54 .2104 during the two years preceding the date of application for reinstatement of licensure.  Complete the Reinstatement Application - Continuing Education Attestation (main list of activities/programs) and individual Continuing Education Attestation Forms for each program/activity you list on the Reinstatement Application Continuing Education Attestation.
      NOTE: No fee is required to apply for reinstatement of licensure. Payment of the renewal ($250.00) and reinstatement ($100.00) fees will be required to be remitted within 30 days after receiving notification from the Board that reinstatement of licensure has been approved.
   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 diploma from the American Board of Professional Psychology, arrange to have ABPP write directly to the NC Psychology Board to verify your ABPP status.
      3. 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.
      4. 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
   1. Print a copy of--or send the link to--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. SUPERVISOR FORM
   1. Print copies of--or send the link to-- the Supervisor Form for each direct supervisor, whether administrative or clinical, who is listed on your Application Form (under #18, Experience Section) to cover the period of time from the date on which your license was suspended due to nonrenewal or was approved by the Board to be relinquished. 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.
   2. 1. 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 supervisor and your name where indicated.
   4. Send a form to each supervisor (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 supervisor’s signature over the seal. Forms submitted to the Board office without the supervisor’s signature over the seal will NOT be accepted.
   5. 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.
   6. 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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7. TRANSMITTAL FORM
   All required supervisor and reference forms must be submitted--in sealed envelopes with the supervisor/reference signature written across the seal (all unsigned envelopes will be returned, which will delay the process)--in one packet directly to the Board by the applicant along with the Transmittal Form. Any written explanation as detailed in Item #5(5) of these instructions must also accompany this Transmittal Form. [NOTE: It is neither recommended nor necessary to wait until all supervisor and reference forms have been collected to submit the initial Application Form, application fee, and Supervision Contract Form.]

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8. HEALTH SERVICES PROVIDER (HSP) APPLICATION FORM
   This certification is in addition to licensure and is mandatory for permanently licensed psychologists who render health services in North Carolina. If the applicant previously held HSP, it is NOT necessary to again apply for this certification; HSP certification will be reinstated along with licensure. However, if the applicant did not previously hold HSP certification and wishes to obtain such at this time, the applicant must complete the HSP Application Form and submit required documentation. Contact the Board office for applicable documentation forms. Certification is optional at the licensed psychological associate and provisional licensed psychologist levels of licensure. HSP certification does NOT transfer between levels of licensure. The $50.00 application fee must be remitted with each application or reapplication for HSP certification.

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9. TRANSCRIPTS
   If your file is no longer maintained in the Board office, you must arrange to have ALL graduate college transcripts (whether or not in the field of psychology) sent directly from your school(s) to the Board. Under current requirements, licensure files are retained only for three years following relinquishment or suspension of a license due to nonrenewal. Copies of transcripts submitted by the applicant are NOT accepted, even if they are in sealed envelopes from the schools.

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10. EXAMINATIONS
    Reexamination may be required for reinstatement of licensure. However, generally, only the State Examination is required. The Board-developed State Examination assesses the applicant’s knowledge of the North Carolina Psychology Practice Act, selected rules of the Board covering such topics as education and supervision, and other legal requirements, and the APA Ethics Code [a copy of which may be obtained from the APA at 750 First Street NE, Washington, DC 20002-4242; Order Department telephone number (800) 374-2721]. The State Examination is currently a 50-item, multiple choice examination, and is administered on computer at PSI testing centers. Upon payment of the $200.00 State Examination fee to the NC Psychology Board, an approved applicant calls PSI to schedule the examination for his or her chosen location and date. [NOTE: Also, see examination requirements in 21 NCAC 54 .1900 (printed at end of the NC Psychology Practice Act under Selected Board Rules).]

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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.