Apply for Licensure

Fingerprint cards for background checks REQUIRED starting NOVEMBER 1, 2016

**NOTE**

Incorporation & PLLC renewals

were mailed December 8. 

REMINDER: If you renew online and have had a change of address, please submit notification to the Board office ASAP using the form found at this link so that your renewal card will be mailed to the correct address.

 Board Meeting Dates

November 9-10, 2017

February 8-9, 2018

May 10-11, 2018

August 9-10, 2018

November 8-9, 2018

Click Here for deadline dates for submitting materials 

FORMS

Applications

APPLICATION FOR HEALTH SERVICES PROVIDER PSYCHOLOGIST (HSP-P) BASED ON MOBILITY CREDENTIAL

APPLICATION FOR LICENSURE FORM

APPLICATION FOR LICENSURE BASED ON MOBILITY CREDENTIAL

APPLICATION FOR REINSTATEMENT OF LICENSURE FORM

DOCUMENTATION OF ORGANIZED HEALTH SERVICES TRAINING PROGRAM (HSP FORM #1)

HEALTH SERVICES PROVIDER (HSP) APPLICATION FORM

HSP FORM#1

LP DOC #2 LICENSED PSYCHOLOGIST APPLICANT SUMMARY SHEET

LP DOC #3 LICENSED PSYCHOLOGIST APPLICANT PROGRAM VERIFICATION FORM

PA DOC #2 PSYCHOLOGICAL ASSOCIATE APPLICANT SUMMARY FORM

PA DOC #3 PSYCHOLOGICAL ASSOCIATE APPLICANT PROGRAM VERIFICATION FORM

PA DOC #4 PSYCHOLOGICAL ASSOCIATE APPLICANT SUPERVISED EXPERIENCE VERIFICATION FORM

REFERENCE FORM

SENIOR PSYCHOLOGIST ATTESTATION FORM

SUPERVISION CONTRACT FORM

SUPERVISOR FORM

TRANSMITTAL FORM

VERIFICATION OF DEGREE FORM

 

Complaint

COMPLAINT/INQUIRY FORM

 

Continuing Education

 

Continuing Education Attestation Form

 

Supervision

Application for Reduced Supervision (RS Form#2)

Alternate Supervision Plan and Requirements

Report for Reduced Supervision (RS Form#3)

Supervision Contract Form and Instructions

Supervision Record Form

Supervision Report Form

 

Provisional to Permanent Licensure

APPLICATION FORM

APPLICATION FOR HEALTH SERVICES PROVIDER

 

Forming a Professional Corporation 

Application for Certificate of Registration of Professional Corporation

 

Making Changes to a Professional Corporation (PC)

Amendment of Name of Corporation

Application to Add Shareholders to a Corporation

Articles of Incorporation

Dissolution of a Corporation

 

Forming a Professional Limited Liability Company (PLLC)

Application for Certification of Registration of PLLC

Articles of Organization

 

Making Changes to a PLLC

Amendment of Articles of Organization

Amendment of Name of PLLC

Application to Add Members to PLLC

Dissolution of a PLLC