21 NCAC 54 .1701. INFORMATION REQUIRED

(a)  Except as provided in Paragraph (b) of this Rule and Rule .1707 of this Section, the information required for each applicant for licensure shall consist of:

(1)           typed or legibly printed, notarized application form;

(2)           application fee;

(3)           typed or legibly printed, notarized supervision contract form;

(4)           signed consent form, completed Fingerprint Record Card, and other such form(s) or information as required by the North Carolina Department of Justice to perform a criminal history record check;

(5)           payment of fee required by the North Carolina Department of Justice to conduct a criminal history record check;

(6)           official transcript(s) sent directly to the Board by any institution of higher education from which the applicant received a graduate degree or otherwise completed graduate course work in psychology;

(7)           completed supervisor forms from present and past supervisors;

(8)           three completed reference forms from professionals who are familiar with the applicant's current work, one of which is from a doctoral level psychologist;

(9)           written verification and report on the status of any occupational licensure, including dates of licensure and any disciplinary action which is pending or has been taken, sent directly to the Board from any other regulatory agency in North Carolina and any other jurisdiction in which the applicant has applied for a license, is currently licensed, or previously was licensed, if applicable;

(10)         official report of any previous score obtained on the Examination for Professional Practice in Psychology sent directly to the Board from the Association of State and Provincial Psychology Boards, if applicable; and

(11)         additional documentation regarding educational credentials described in 21 NCAC 54 .1802 and 21 NCAC 54 .1803, if applicable.

(b)  The information required for each applicant applying for licensure on the basis of holding a current credential for psychology licensure mobility shall consist of:

(1)           typed or legibly printed, notarized application form;

(2)           affidavit which attests to having no unresolved complaint in any jurisdiction at the time of application in North Carolina;

(3)           application fee;

(4)           typed or legibly printed, notarized supervision contract form;

(5)           signed consent form, completed Fingerprint Record Card, and other such form(s) or information as required by the North Carolina Department of Justice to perform a criminal history record check;

(6)           payment of fee required by the North Carolina Department of Justice to conduct a criminal history record check;

(7)           official transcript sent directly to the Board by the institution of higher education from which the applicant received his or her doctoral degree in psychology; or if applicable, a copy of the transcript sent directly to the Board by either the Association of State and Provincial Psychology Boards, National Register of Health Service Providers in Psychology, or American Board of Professional Psychology;

(8)           three completed reference forms from professionals who are familiar with the applicant's current work, one of which is from a doctoral level psychologist;

(9)           written verification and report on the status of any occupational licensure, including dates of licensure and any disciplinary action which is pending or has been taken, sent directly to the Board from any other regulatory agency in North Carolina and any other jurisdiction in which the applicant has applied for a license, is currently licensed, or previously was licensed;

(10)         written verification sent directly to the Board from the applicable organization(s) that the applicant holds a current credential in good standing for psychology licensure mobility, as follows:

(A)          Certificate of Professional Qualification (CPQ) from the Association of State and Provincial Psychology Boards;

(B)          registrant in the National Register of Health Service Providers in Psychology; or

(C)          diplomate of the American Board of Professional Psychology; and

(11)         documentation of meeting requirements for health services provider certification as specified in Section .2700 of this Chapter, if applicable.

(c)  An application shall contain all required materials to be complete.  An incomplete application shall be active for three months from the date on which the application is received in the Board office.  At the end of such time, if still incomplete, the application shall be void, and the applicant shall be deemed to have discontinued the application process. If the individual chooses to pursue licensure at a later date, the individual shall totally reapply.

(d)  To be considered to have made application pursuant to G.S. 90-270.5(a), the information specified in Subparagraphs (a)(1) through (a)(5) of this Rule, or Subparagraphs (b)(1) through (b)(6) of this Rule if applying on the basis of a mobility credential, shall be filed in the Board office within 30 days of offering to practice or undertaking the practice of psychology in North Carolina.

 

History Note:        Authority G.S. 90-270.4(h); 90-270.5(a); 90-270.9; 90-270.11(a),(b); 90-270.13(a) (b); 90-270.15; 90-270.22(a);

Eff. September 1, 1982;

Amended Eff. March 1, 2008; September 1, 2005; January 1, 1996; November 1, 1991; March 1, 1989; June 1, 1988.