21 N.C. Admin. Code 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) a typed or printed, signed or digitally signed application form. The form shall include the following information:

(A) legal name;

(B) home mailing address and telephone number;

(C) business name, mailing address and telephone number;

(D) preferred mailing address;

(E) Social Security number;

(F) e-mail address;

(G) date and place of birth;

(H) licensure or applicant for licensure by another psychology board;

(I) if taken, the score on the Examination for Professional Practice in Psychology;

(J) if previously an applicant for a license to practice psychology in North Carolina;

(K) if denied a professional license or permit, or privilege of taking an examination;

(L) had a professional license or permit ever disciplined by any licensing authority in North Carolina or elsewhere;

(M) whether aware of any pending charges against a professional license or permit which are held;

(N) if ever withdrawn an application for licensure or an application to take a professional licensing examination in North Carolina or elsewhere;

(O) if ever been convicted of, or entered a plea of guilty or nolo contendere to any felony or misdemeanor other than a minor traffic violation;

(P) other fields of work for which the applicant is licensed or certified, or has applied for licensure or certification;

(Q) whether the applicant holds a diploma from the American Board of Professional Psychology;

(R) whether doctoral program was APA accredited at the time of your graduation;

(S) names of graduate programs attended and dates degrees awarded;

(T) names and mailing addresses of three professional references, other than supervisors;

(U) all work experience, including, any graduate internship, practicum, or other supervised training experience that serves as the basis for the current application for licensure;

(V) any disability that may require an accommodation in taking licensing examinations; (W) if applying for Health Services Provider Certification;

(X) if applying for senior psychologist as specified in Rule .1707 of this Section; and

(Y) certify that the applicant has read and understands the public notice statement on employee misclassification maintained on the Board's website and whether the applicant has been investigated for employee misclassification within the past 12 months.

(2) the application fee under Rule .1605(7) of this Chapter;

(3) a typed or printed, signed or digitally signed supervision contract form. The form shall include the following information:

(A) supervisee's name, North Carolina psychology license number and level, mailing address, e-mail address and telephone number;

(B) supervisee's current work setting;

(C) if supervision contract form is for an applicant or replaces previous supervision contract form(s);

(D) supervisor's name and psychology license number, business telephone number, business name and address;

(E) if the supervisor has;

(i) been denied a professional license or permit;

(ii) had any disciplinary, remedial, rehabilitative, or other action taken against a professional license, certificate, or permit by any licensing or certification authority in North Carolina or elsewhere; or

(iii) if aware of any pending charges against a professional license, certificate, or permit;

(F) if the supervisee has:

(i) been denied a professional license or permit;

(ii) had any disciplinary, remedial, rehabilitative, or other action taken against a professional license, certificate, or permit by any licensing or certification authority in North Carolina or elsewhere; or

(iii) if aware of any pending charges against a professional license, certificate, or permit;

(G) number of hours per week engaged in the practice of psychology;

(H) number of hours allotted for individual supervision per week;

(I) number of individual supervision sessions per week; and

(J) if supervision is not required under Rule .2008 of this Section.

(4) a signed fingerprint search consent form, which may be downloaded from the Board's website; a completed Fingerprint Record Card, which can be obtained from the Board office or a local Sheriff's office; 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) an official transcript(s) sent 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) the completed supervisor forms completed by present and past supervisor. The form shall include the following information:

(A) names of applicant and supervisor;

(B) institution or setting where applicant was supervised;

(C) supervisor's position at the time supervision occurred;

(D) applicant's position or title;

(E) dates of applicant's employment or training;

(F) dates of supervision of applicant;

(G) number of hours per week applicant practiced psychology under supervisor's direction;

(H) number of weeks during which applicant practiced psychology under supervisor's direction;

(I) number of practice of psychology hours accumulated;

(J) number of health services hours accumulated;

(K) number of hours per week of individual face-to-face supervision;

(L) duties performed by applicant;

(M) if supervisor is licensed as a psychologist in North Carolina or in any other state or jurisdiction in the U.S. or Canada; and

(N) if the applicant is competent to practice 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. The reference form shall include:

(A) names of reference and applicant;

(B) time period reference has known applicant;

(C) nature of professional relationship;

(D) judgment regarding the applicant's training, experience, professional skills, adherence to

(E) legal and ethical standards; and

(F) areas of concern, further comments, and recommendations to the Board.

(9) a written verification and report on the status of any occupational licensure, including dates of licensure and any disciplinary action that 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) an 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) any additional documentation regarding educational credentials described in Rules .1802 and .1803 of this Chapter, if requested by the Board.

(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 printed, signed or digitally signed application form. The form shall include the following information:

(A) legal name;

(B) home mailing address and telephone number;

(C) business name, mailing address and telephone number;

(D) Social Security number;

(E) e-mail address;

(F) date and place of birth;

(G) licensure or applicant for licensure by another psychology board;

(H) if:

(i) been denied a professional license or permit, or privilege of taking an examination;

(ii) had a professional license or permit disciplined in any way; or

(iii) if aware of any pending charges against a professional license or permit;

(I) if ever have withdrawn an application for licensure or an application to take a professional licensing examination;

(J) if ever have been convicted of, or entered a plea of guilty or nolo contendere to any felony or misdemeanor other than a minor traffic violation;

(K) other fields of work for which the applicant is licensed or certified, or has applied for licensure or certification;

(L) if holds a CPQ issued by the Association of State and Provincial Psychology Boards;

(M) if registrant in the National Register of Health Service Providers in Psychology;

(N) if holds a diploma from the American Board of Professional Psychology;

(O) names of graduate programs attended and dates degrees awarded;

(P) names and mailing addresses of three professional references, other than supervisors;

(Q) all work experience including, any graduate internship, practicum, or other supervised training experience that serves as the basis for current application for licensure;

(R) any disability that may require some special accommodation in taking licensing examinations;

(S) if applying for Health Services Provider Certification; and

(T) certify that the applicant has read and understands the public notice statement on employee misclassification maintained on the Board's website and whether the applicant has been investigated for employee misclassification within the past 12 months.

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

(3) application fee under Rule .1605(7) of this Chapter;

(4) typed or printed, signed or digitally signed supervision contract form as described in Subparagraph (a)(3) of this Rule;

(5) signed consent form, which can be downloaded from the Board's website, completed Fingerprint Record Card, which can be obtained from the Board office or a local Sheriff's office, 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 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, as described in Subparagraph (a)(8) of this Rule, 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 from one of the following:

(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 materials required under Paragraph (a) or (b) of this Rule to be complete. The application forms may be found on the Board website. 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 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.

Notes

21 N.C. Admin. Code 54 .1701

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. Readopted by North Carolina Register Volume 34, Issue 21, May 1, 2020 effective 4/1/2020.