Forms for Psychologist Applications

Applicants: 

Download the individual forms below, as needed. The PDFs are form-fillable. Use Adobe Acrobat or Adobe Reader.  Do not use other apps or programs to complete the forms.  Some fields will not be visible in your browser or via another program/app. Forms received in an altered format will be rejected. 

 

  • Core Program Requirements form: (Needed only if your doctoral program is NOT APA or PCSAS accredited.) Upload with your online application where indicated. 
  • Statement of Citizenship or Alien Status Form:  All applicants are required to complete and submit this form, and provide proof of lawful status in the United States. See the evidence list on page 3 for accepted forms of ID.  This form needs to be uploaded with your online application where indicated. You must also upload an appropriate ID per the evidence list. 
  • Appropriate Documentation for "YES" Answers:  If you have answered Yes to a professional conduct (declaration) question, additional documentation is required. Download this PDF for a list of the possible declaration questions and the associated documentation or evidence that the applicant must submit to the Board if the applicant’s answer to a declaration question is “yes”. Applications will not be considered administratively complete without these materials. 



PRIMARY SOURCE VERIFICATIONS (PSVs)

DO NOT submit PSVs with your application.  A PSV is not valid if submitted by an applicant. A PSV must be submitted by the verifier directly to the Board's office in order to be valid.  The verifier must email the verification to [email protected]. The submissions email address is monitored strictly for document submissions. (For questions, see the Contact Us page for Board staff email addresses.)

NOTE ABOUT VERIFIERS:  Training records for psychologists must be retained permanently. If you are unable to contact your supervisor or director of training, or these psychologists are no longer with your program or site, you may request the current licensed psychologist in that position who is the current custodian of your training records to complete the verification.

  • Preinternship/practicum: Supervised Preinternship Experience Summary. (Needed only if you are applying preinternship hours towards licensure. This is a tool to assist you in completing page 2 of the Supervised Preinternship Experience Verification form, below, and to assist the Board in reviewing your preinternship verification.)
  • Preinternship/practicum: Supervised Preinternship Experience Verification form.  This PSV is needed only if you are applying preinternship hours towards licensure. Not needed if you have been licensed in another state for 10 years or more - you may waive the requirement to have additional hours verified.  Not needed for temporary license application. Must be submitted by your supervisor or director of training directly to the Board's office. 
  • Preinternship/practicum: Preinternship Verification form - Page 2.  This PSV is needed if you are applying preinternship hours towards licensure and have multiple sites. Complete this page for each individual site. If you have 3 sites, there should be 3 copies of this page in the verification, one for each site. Complete the top section. Your training director needs to complete the bottom section to verify that the information you provided is true and correct according to the training records. Print to PDF before attempting to combine pages into one PDF document. Combining form-fillable PDFs while the fillable fields are active will cause the data to change. The pages may also be submitted separately, without combining. 
  • Internship: Supervised Psychology Internship or Training Experience Verification form.  This PSV is needed if you are applying via the Psychologist Application for Exam and/or Licensure form and have been licensed less than 20 years. 
  • Postdoc: Postdoctoral Professional Psychology Experience Verification. This PSV is needed only if you are applying postdoctoral hours towards licensure.  If you have been licensed in another state for 10 years or more, you do not need this form, because you may waive the requirement to have additional hours verified. Not needed for temporary license application. Must be submitted by your supervisor directly to the Board's office.
  • License Verifications: Verification of Licensure is required from every state or province that has ever issued the applicant a license, registration and/or certification for any profession, regardless of current status (active, inactive, expired, revoked, surrendered, or otherwise). 
    • A form is NOT provided for license verifications, which are PSVs.  Many boards, including Arizona's Board of Psychologist Examiners, no longer produce written PSVs of licensure separate from their online license lookups. If any of your other licensing Boards have an online license lookup  that states it is a "primary source verification", please upload a screenshot or PDF of the online verification at the appropriate point in the online application. If the primary source verification statement is on a separate page of that Board's website, please include a PDF or screenshot of this statement with the verification. (Use a Snip tool/app to take a screenshot, paste it into a Word document, repeat as needed if the PSV statement is on a separate web page, then print to PDF. )
    • If any of your other licensing Boards do not have the PSV statement on their online license lookups/licensee searches, applicants are responsible to contact the licensing Boards to request verification of the license be sent to the Arizona Board. Each state has their own requirements for this. The applicant is responsible for any fees incurred. 

    • Make sure to include ALL U.S. states, districts and territories, as well as any Canadian provinces in which you hold or have ever held a license, regardless of current status of that license, in the applicable fields of the online application. Failure to do so is considered unprofessional conduct per A.R.S. § 32-2061(16) and can result in denial of the application or future disciplinary action against an Arizona license.