Section 868IAC1.1-13-4. Application

   (a) Any person seeking endorsement as a health service provider in psychology must apply on such form and in such manner as the board shall prescribe.

  (b) All applicants will be required to provide verification of experience in a [sic, an] internship. Verification of the internship shall be provided on a form supplied by the board or a photocopy thereof. The verification form shall be completed and signed by the director of training of the internship. If the director of training is not available for completion of the verification form, for good cause shown, another psychologist associated with the internship may complete the form. The applicant shall notify the board in writing if a supervisor is not available and the reason therefor.

  (c) The internship verification form shall include the following:

(1) The name and address of the agency providing the internship.

(2) A description of the internship's patient population.

(3) The exact beginning and ending dates of the applicant's training in the internship.

(4) An indication of whether or not the internship was accredited as a [sic, an] internship by the American Psychological Association.

(5) The number of hours per week the applicant worked in the internship setting.

(6) The number of hours per week the applicant received direct, face-to-face supervision from:

(A) the identified supervisor; and

(B) other licensed or certified psychologists employed by the internship program.

(7) The exact beginning and ending dates of the supervisor's supervision of the applicant.

(8) A brief description of the applicant's internship experience while under the supervisor's supervision.

(9) A brief statement by the supervising psychologist describing the psychologist's professional qualifications.

(10) The total number of hours of supervised experience completed by the applicant.

(11) A statement by the supervisor indicating whether or not the internship was satisfactorily completed.

(12) The signature of the supervisor attesting to the truthfulness of the statements made on the form.

  (d) All applicants will be required to provide verification of doctoral level practicum experience or post-internship, or both, as specified in section 3.1 of this rule. Verification of this experience shall be provided on a form supplied by the board or a photocopy thereof. The verification form for doctoral level practicum experience shall be completed and signed by the director of training or designee of the applicant's program. The verification form for post-internship experience shall be completed and signed by each psychologist who provided supervision to the applicant during the post-internship supervised experience. If a supervisor is not available for completion of the verification form, for good cause shown, the program director or another psychologist associated with the post-degree experience may complete the form. The applicant shall notify the board in writing if a supervisor is not available and the reason therefor.

  (e) The verification form for the doctoral level practicum experience shall include the following:

(1) The name and address of the doctoral level practicum program.

(2) A description of the practicum setting or settings.

(3) The exact beginning and ending dates of the applicant's experience in each setting.

(4) The date that the basic practicum hours completed.

(5) The number of hours per week the applicant worked in the setting.

(6) The number of hours per week the applicant received direct, face-to-face supervision from the supervisor.

(7) A brief description of the training program's oversight of the setting.

(8) The total number of hours of direct patient contact by the applicant in each practicum setting.

(9) The total number of hours of supervised experience completed by the applicant.

(10) The signature of the training director attesting to the truthfulness of the statements made on the form.

  (f) The verification form for the post-internship experience shall include the following:

(1) The name and address of the setting in which the experience was obtained.

(2) A description of the setting's patient population.

(3) The exact beginning and ending dates of the applicant's experience in the setting.

(4) The number of hours per week the applicant worked in the setting.

(5) The number of hours per week the applicant received direct, face-to-face supervision from the supervisor.

(6) The exact beginning and ending dates of the supervisor's supervision of the applicant.

(7) A brief description of the applicant's experience while under the supervisor's supervision.

(8) A brief statement by the supervising psychologist describing the psychologist's professional qualifications.

(9) The total number of hours of direct patient contact by the applicant.

(10) The total number of hours of supervised experience completed by the applicant.

(11) A statement by the supervisor indicating whether or not the supervised experience was satisfactorily completed.

(12) The signature of the supervisor attesting to the truthfulness of the statements made on the form.

(State Psychology Board; 868 IAC 1.1-13-4; filed May 8, 1992, 5:00 p.m.: 15 IR 1961; readopted filed Apr 23, 2001, 11:30 a.m.: 24 IR 2896; readopted filed Oct 4, 2007, 3:32 p.m.: 20071031-IR-868070065RFA; filed Sep 8, 2010, 11:38 a.m.: 20101006-IR-868090925FRA)